The Neurotopian

Spiegeltherapie für alle - Teil 4

2010-07-08T07:02:00.000-07:00

Erweiterung der Spiegeltherapie - Feedbacktherapie

Die klassische Spiegeltherapie wird - wie der Name schon sagt - mit Hilfe eines Spiegels durchgeführt.

Betrachtet man aber das Prinzip hinter dieser Art der Therapie - und löst sich vom Gedanken an den Spiegel - öffnen sich ungeahnte Möglichkeiten, auch andere Arten von chronischen Schmerzen zu behandeln.

Bei Querschnittslähmungen hat man ja keine gesunde Seite mehr die man bewegen kann - also kann ein Spiegel auch nicht funktionieren?!

Dieses Problem - und die Lösung gleich dazu ;-) - habe ich im März 2003 beschrieben - in der Yahoo Gruppe Supertraining, Message 29357.
Zu meiner grossen Freude habe ich die passende Software Lösung dazu im April 2010 auf der NOI Konferenz in Nottingham kennengelernt: das NOI Move Programm.

Alles was man dazu benötigt ist ein Computer, eine Webcam und Internetzugang.
Man sitzt/steht vor der Webcam die den Oberkörper filmt. Im unteren Bereich des Bildschirms werden Beine eingeblendet die sich bewegen. So erhält unser Gehirn visuelles Feedback von den Beinen - auch wenn man diese aus eigener Kraft nicht mehr bewegen kann.

Grössere Studien, die den Effekt dieser Art der Therapie untersuchen, sind bereits geplant und sollten in den nächsten Jahren Ergebnisse liefern. Die Software ist kostenfrei verfügbar - nur leider hat es sich noch nicht genug herumgesprochen, dass es sie gibt.

Dabei gibt es doch nichts Schöneres als mit anderen zu teilen. ;-)

Unser Gehirn bevorzugt visuelles Feedback. Aber wenn, wie bei Rückenbeschwerden, der Rücken nicht zu sehen ist, dann gibt sich das Gehirn auch gerne mit taktilen Reizen (Berührung) zufrieden.

Das Problem liegt eher darin dass von unserem Rücken zu wenig Signale an das Gehirn gesendet werden.

Hier besteht die "Spiegeltherapie" - oder eben besser gesagt - die Feedbacktherapie - daraus, wieder Reize zu setzen:
mit Bürsten, Igelbällen, etc.

Das Gehirn kann den Körper gut steuern - muss aber wissen in welchen Bereichen es eingreifen muss.
Dazu braucht es Feedback - eine Rückmeldung die dem Gehirn anzeigt wie es seinen Output anpassen muss.

Man sieht das bei gehörlosen Menschen sehr gut: sie hören sich selbst nicht - bekommen also kein Feedback - und lernen daher das sprechen nicht. Der gleiche Mechanismus steht hinter vielen Arten von chronischem Schmerz.

Die Feedbackschleife wird unterbrochen und die Steuerung läuft aus dem Ruder.

Spiegeltherapie für alle - Teil 3

2010-07-08T04:47:00.000-07:00

Wirkungsweise

Die Therapie wurde das erste Mal Mitte der 90er Jahre beschrieben.
Das ist bei weitem nicht genügend Zeit, um die Wirkungsweise bis ins letzte Detail erforscht zu haben.

Das soll uns aber nicht daran hindern, schon jetzt überaus erfolgreich mit der Methode zu arbeiten und sie auszubauen.

Der wichtigste Punkt der sich aus den schon vorhandenen Forschungen ergibt ist:
unser Gehirn bleibt ein Leben lang lernfähig. Es ist "plastisch".

Dies ermöglicht es uns neue Sprachen zu lernen, neue Fähigkeiten zu lernen (z.b. jonglieren) - und auch uns nach schweren Traumen wieder mehr oder weniger zu erholen (z.b. Schlaganfall).

Diese Fähigkeit des Gehirns beruht auf verschiedenen Mechanismen:
- stumme Verbindungen sind Kontakte zwischen Nervenzellen die normalerweise nicht aktiv sind. Nur bei extremen Umständen werden diese aktiv.
- Neubildung von Nervenzellen in kleinem Ausmass könnte auch zur Erholung beitragen. Man hat erst vor wenigen Jahren herausgefunden dass überhaupt neue Nervenzellen gebildet werden. Wie diese dann im Gehirn verwendet werden ist bis jetzt noch nicht geklärt.
- angrenzende Bereiche übernehmen zum Teil die Funktion des Bereichs der ausgefallen ist.

Diese "Selbstheilungskräfte" des Gehirns sind erstaunlich - haben aber auch das Potential für Probleme zu sorgen.
Das Gehirn kann nämlich chronische Schmerzen erlernen.
Dabei werden bestimmte Areale, die für die Darstellung der Körperoberfläche zuständig sind, verändert.

Signale die von aussen an das Gehirn gesendet werden sind zunächst "neutral", d.h. es gibt kein Schmerzsignal auf dem Weg zum Gehirn.
Dass diesen Rezeptoren der Begriff "Nozizeptoren" (Schmerzrezeptoren) gegeben wurde, war ein grosser Fehler.
Besser ist es diese Signale als Warnsignale zu beschreiben - denn das ist ihre tatsächliche Aufgabe.

Denn letztendlich entscheidet erst das Gehirn ob Schmerz wahrgenommen wird oder nicht.

Bei chronischen Schmerzen geht man davon aus, dass das Gehirn gelernt hat, harmlose Warnsignale als schmerzhaft zu interpretieren.
Hier können u.a. Dinge wie ein falsches Verständnis von Schmerz eine Rolle spielen. Also im weitesten Sinn die Art und Weise wie man mit Schmerz umgeht, welchen Bewegungen/Tätigkeiten man die Ursache für die Schmerzen gibt usw.

Deswegen ist nach dem Biopsychosozialen Modell auch eine interdisziplinäre Therapie bei chronischen Schmerzen nötig. Hier arbeiten Ärzte, Therapeuten, Psychologen, Sozialberater und andere zusammen, um das Problem von allen Seiten anzugehen.

Zurück aber zum Gehirn:
werden Warnsignale über einen längeren Zeitraum als schmerzhaft empfunden, so kann sich ein Schmerzgedächtnis ausbilden.
Das heisst, das Gehirn hat den Schmerz fest abgespeichert bzw. erlernt.
So wird dann, auch wenn die Verletzung schon längst abgeheilt ist, weiterhin - direkt vom Gehirn aus (!) - Schmerz erzeugt.

Das Gehirn hat etwas erlernt, das für den Patienten nicht sinnvoll bzw. hilfreich ist - eher das Gegenteil.

Die Therapie muss also diesen Lernprozess rückgängig machen.
Therapie stellt ein umlernen dar - nicht ein reines Training im Sinne von Kraft- und Muskelaufbau wie es von vielen fälschlicherweise verstanden wird.

Und lernen funktioniert nur, wenn unsere Aufmerksamkeit auf das gerichtet ist was wir gerade machen.

Die Wirkungsweise der Spiegeltherapie kann man demnach so beschreiben:
"Spiegeltherapie ist ein (Um-)Lernprozess, bei dem man mittels gelenkter Aufmerksamkeit dem Gehirn ermöglicht zwischen harmlosen und echten Warnsignalen zu unterscheiden".

Das Gehirn muss "merken" wo die Grenze liegt, die bei chronischen Problemen im Laufe der Zeit immer mehr nach unten verschoben wird.

Dies kann dazu führen, dass bereits normale Bewegung schmerzhaft ist. Über die Spiegeltherapie kann man dem Gehirn eine Alternative anbieten: die Bewegung des gesunden Arms ist schmerzfrei. Über die Spiegelung "sieht" das Gehirn die betroffene Seite und wie sie sich ohne Probleme bewegen lässt. Diese Illusion reicht oft schon aus um auf der betroffenen Seite den Schmerz zu reduzieren.

Das Gehirn hört auf die Signale von der betroffenen Hand als schmerzhaft zu interpretieren.
Danach kann dann die restliche Therapie ansetzen.

Spiegeltherapie für alle - Teil 2

2010-07-08T02:45:00.001-07:00

Durchführung

die klassische Spiegeltherapie wird so durchgeführt:

Die betroffene Seite (Arm, Hand, Bein) befindet sich hinter dem Spiegel (so dass man auch aus dem Augenwinkel nichts davon sehen kann), die nicht betroffene Seite vor dem Spiegel.

Im Bild wird nun die rechte Hand gespiegelt - und es entsteht die Illusion einer gesunden und frei beweglichen linken Hand.
Wichtig dabei ist, dass die gefühlte Position und die des Spiegelbildes übereinstimmen. Ist der Spiegel z.b. zu stark gekippt, dann funktioniert die Illusion bei weitem nicht so gut.

Zunächst sollte auch die Umgebung relativ frei von Ablenkungen sein.
Die Aufmerksamkeit muss komplett dem Spiegelbild gelten.

Auch dürfen die Arme nicht zu weit auseinander liegen. Abstände bis zu 50cm geben die besten Resultate.
Bewegt man die Hände, dann geht die betroffene Seite nur bis zur Schmerzgrenze - nicht darüber!

Spiegeltherapie muss als Training verstanden werden:
das Gehirn hat den (chronischen) Schmerz erlernt - und die Therapie muss diesen Lernvorgang rückgängig machen.
Analog zum sportlichen Training gibt es also ein paar einfache Regeln zu beachten:

1) den aktuellen Trainingslevel finden, d.h. auf welcher Stufe muss das Training beginnen?
Wenn möglich, bewegt man beide Hände gleichzeitig. Hier kann man seiner Phantasie freien Lauf lassen: Finger öffnen und schliessen, den Daumen und die Fingerspitzen zusammenbringen, das Handgelenk beugen und strecken, etc.

Ist dies nicht möglich, weil z.b. verstärkt Schmerzen auftreten, dann bleibt die betroffene Hand zunächst hinter dem Spiegel liegen und nur die gesunde Hand bewegt. Weiter reduzieren kann man das Training indem beide Hände auf dem Tisch liegen und man zunächst nur das Spiegelbild betrachtet.

Sollte auch dies zu Problemen führen müssen andere Therapien vorgeschaltet werden (Imaginationstraining). Dies ist aber nur bei einer sehr sehr kleinen Patientengruppe nötig die von CRPS (bzw. Morbus Sudeck) betroffen sind.

2) Steigerung:
je nach aktuellem Trainingszustand stellt sich die Steigerung so dar:
- beide Hände liegen, keine Bewegung
- betroffene Hand liegt, gesunde Hand bewegt
- beide Hände bewegen (einfache Muster)
- beide Hände bewegen (komplexe Muster)
- beide Hände bewegen - Ablenkung von aussen wird eingebaut

Steigern kann man oft sehr schnell. Sobald eine Stufe toleriert wird, d.h. es zu keiner Schmerzverstärkung kommt, probiert man die nächste Art von Bewegung. Es ist nicht ungewöhnlich innerhalb einer Therapieeinheit alle 5 Stufen zu durchlaufen.

Bei den nachfolgenden Einheiten kann man natürlich dann direkt bei der letzten erreichten Stufe einsetzen. Denn eine Reduzierung ist jederzeit wieder möglich, sollten sich Schmerzen einstellen.

3) Alltagsbezug:
wir dürfen in der Therapie nicht vergessen, dass unsere Arbeit (für den Patienten) sinnvoll sein muss.
Es gibt Alltagsbewegungen die gemeistert werden müssen.

Es ist nicht nur der Schmerz an sich, der eine grosse Beeinträchtigung darstellt, sondern auch das auf-andere-angewiesen sein, das als störend empfunden wird.

Die Therapie muss sich daher auch an genau diesen Einschränkungen orientieren und sie wieder trainieren. Dabei können Hilfsmittel wie Besteck, Geschirr, Bürsten, Stifte, etc. zum Einsatz kommen.

Bei Schulterproblemen bietet es sich an, z.b. die Haare zu kämmen. Dabei muss dann der Kopf noch etwas seitlicher vom Spiegel positioniert werden, damit man die Bewegung gut sehen kann.

4) Dauer und Häufigkeit:
In der Praxis zeigt sich, dass eine Dauer vom 10min pro Trainingseinheit ausreichend ist. Die Konzentrationsfähigkeit lässt auch nach dieser Zeit nach und der Effekt wird geringer.
Zur Häufigkeit: 2-3 mal pro Tag, täglich für mehrere Wochen (bis zum gewünschten Erfolg).

Bei periodisch auftretenden Schmerzen kann man die Therapie natürlich auch nur im Bedarfsfall anwenden.

5) Besonderheiten:
wird die Therapie nur zur Schmerzreduktion eingesetzt, so steht das Bewegungsausmass beider Gliedmaßen nicht im Vordergrund. Man bewegt einfach beide Körperteile synchron und geht keinesfalls über die Schmerzgrenze.

Möchte man aber ein Gelenk wieder "fit" machen, z.b. nachdem es mehrere Wochen in einer Schiene/Gips gelagert war, dann bewegt man die gesunde Seite (die sich ja dann als betroffene Seite spiegelt) - weiter als es eigentlich möglich ist.
Die betroffene Seite geht bis ans Bewegungsende, die gesunde Seite so weit wie möglich.

Durch die Ruhigstellung hat das Gehirn verlernt dass sich der Arm/die Hand bewegen lässt - und über die übertriebene Bewegung der gesunden Seite kann man diese Schonhaltung schnell "löschen".
Aus eigener Erfahrung mit Patienten, lassen sich diese "erlernten" Einschränkungen innerhalb von 1-2 Tagen vollständig beseitigen.

Auch auf die Gefahr hin mich zu wiederholen:
die Spiegeltherapie ist nur ein Teil der gesamten Therapie.
Besteht eine Frozen Shoulder schon über einen Zeitraum von 6 Monaten, so haben sich im Gelenk weitreichende Veränderungen ergeben.
Diese müssen natürlich nach und nach angegangen werden - durch intensives Training und Mobilisation.

Ist aber der Schmerz erstmal beseitigt, dann ist die nachfolgende Therapie wesentlich angenehmer. ;-)

Hier noch eine kleine Fallstudie die zeigt, wie schnell man bei einem Patienten die Beweglichkeit mit dem Spiegel verbessern kann:

Spiegeltherapie für alle - Teil I

2010-07-08T00:48:00.000-07:00

Die Spiegeltherapie ist eine in den 90er Jahren entwickelte Methode zur Behandlung verschiedenster chronischer Schmerzyndrome.
Professor Ramachandran und sein Team haben sich zunächst auf Phantomschmerzen konzentriert und die Effektivität dafür nachgewiesen.
In den vergangenen Jahren wurden jedoch auch bei anderen Krankheitsbildern sehr gute Verbesserungen erzielt.

Therapie bedeutet in den meisten Fällen, dass der Patient jemanden aufsucht (einen Arzt, einen Therapeuten, etc.), der dann die geeignete Massnahme durchführt.
Unwillkürlich entsteht dabei oft der Eindruck, dass der Patient nichts selber gegen sein Problem unternehmen kann.

Spiegeltherapie geht hier genau den entgegengesetzten Weg:
der Patient muss selbst aktiv werden - sonst kann kein Effekt eintreten.
Auch die Regelmässigkeit des Trainings führt dazu, dass die Verantwortung für die Therapie beim Patienten liegt.

In der Praxis zeigt sich auch, dass die Spiegeltherapie sehr schnell zu einer Verbesserung (v.a. der Schmerzwahrnehmung) führt.
So ist der Patient motiviert die Therapie auch durchzuführen - weil sich nach jeder Eigenbehandlung Fortschritte zeigen.

Somit ergibt sich eine wesentlich bessere Zusammenarbeit zwischen Therapeut und Patient.

Bei welchen Krankheitsbildern lässt sich die Therapie anwenden?

Erfahrungsberichte gibt es aus den Bereichen Phantomschmerzen, CRPS (auch Morbus Sudeck genannt), Arthritis, Frozen Shoulder, Trigeminus Neuralgien, Querschnittslähmungen, Schlaganfälle, Dystonien und vielem mehr.

Bevor man sich zu viele Hoffnungen macht hier der wichtigste Punkt zur Spiegeltherapie:
es ist primär eine Behandlung, die den Schmerz beeinflusst!

Am Beispiel von Amputationen ist dies gut zu sehen:
Phantomschmerz wird in den meisten Fällen empfunden, weil sich das Phantomgliedmass in einer verkrampften Stellung befindet, d.h. die Finger der amputierten Hand werden als permanent angespannt empfunden. Sie lassen sich nicht mehr in eine entspannte Position bringen.

Mit Hilfe der Spiegeltherapie kann man diese Verkrampfung lösen - und hat danach nur noch die Empfindung einer Phantomhand - die sich aber nicht störend oder schmerzhaft äussert.

Bei einigen Krankheitsbildern ist neben dem Schmerz auch die Beweglichkeit erheblich eingeschränkt - z.b. bei der Frozen Shoulder. Auch hier lässt sich teils innerhalb von wenigen Tagen der Schmerz massiv reduzieren - aber die Beweglichkeit bleibt trotzdem reduziert.

Hier ist die Spiegeltherapie also nur ein kleiner Baustein in der gesamten Therapie; wenn auch aus meiner Sicht einer der wichtigsten. Es ist ein erheblicher Unterschied, ob ich versuche eine schmerzhafte Schulter wieder "in Gang zu bringen" - oder ob ich das auch ohne Schmerzen erreichen kann.

Klassische "Hausaufgaben", die während der Therapie vermittelt werden, zeigen oft keinen unmittelbaren Effekt auf das Schmerzempfinden des Patienten.
Deswegen ist oft die "Compliance" (die aktive Mitarbeit an der Therapie) mangelhaft - und das zu Recht.
Wieso soll ich eine Massnahme durchführen die "mir nichts bringt".

Die Spiegeltherapie ist hier eine sehr gute Methode eben genau diese aktive Mitarbeit zu fördern - denn der Effekt ist in der Regel innerhalb der ersten 2-3 Minuten erreicht.
Selbst wenn der schmerzreduzierende Effekt länger auf sich warten lässt, ist doch das Gefühl der optischen Täuschung/Illusion so neuartig dass die meisten Patienten es gerne auch zuhause wiederholen.

Man könnte die Spiegeltherapie auch als die "ohne Worte" Therapie beschreiben - sie spricht für sich selbst. ;-)

In den folgenden Teilen beschreibe ich die tatsächliche Durchführung, die (vermutete) Wirkungsweise - und das was mir sonst noch dazu einfällt. ;-)

Als Zusammenfassung:

"Spiegeltherapie ist......"
- einfach anzuwenden
- primär eine Behandlung die der Schmerzreduktion dient
- Therapie die der Patient selbständig durchführen muss
- Training (und muss auch gesteigert werden)
- kostengünstig
- motivierend
- effektiv
- ausbaufähig (d.h. es steckt mehr dahinter als wir uns vorstellen können)

Kurz:
ich liebe die Spiegeltherapie ;-)

Embodied Cognition

2010-02-13T10:20:00.000-08:00

Consider this: you are doing a jigsaw puzzle. You have started out - as most people do - looking for the easy pieces that make up the frame of the puzzle.
You did this because those pieces have a straight line on one side - making them relatively easy to pick out of the heap of a thousand or more pieces.

Now - as you start working on more difficult parts of the puzzle - you pick up each new piece and try to match the individual pattern and shape to other pieces that are already in place.
While you are doing this - you are automatically turning the piece you are holding around on it's different axes - trying to see if the piece will fit.

At this point allow yourself a break - lean back and start thinking. ;-)

What just happened?

I won't lie to you: I don't know.
But what I do know is that by examining this question we are one step further along in solving the problem of how to treat chronic pain.
That's a bold claim - but one I feel very confident about.

Here's why:
your brain is - as you will know - a great pattern recognition machine.
It's also pretty good at mental rotation and judging distances, etc. - just think about driving a car and trying to get through a tight alley; your brain creates a map of the space surrounding the car, factors in the dimensions of the car and "tells" you that you will fit through.
And as with everything else - some people are better at that stuff than others ;-) (think fighter pilots or Air Traffic Controllers).

So mentally rotating the piece you are holding in your hand should be pretty easy - right?
It is; but still most of us prefer to do it "in real space".
Why?

a) Brains are lazy
b) Brains take all the help they can get
c) the Brain doesn't care about the bodies boundaries
d) computation can take place anywhere

Let me explain:
a) Brains are lazy

Thinking uses up a lot of energy - tons of it.
And since brains evolved under circumstances where food was scarce saving energy makes sense.

Which brings us to:
b) Brains take all the help they can get

It makes sense to transfer the workload away from the brain.
Why not use a calculator instead of solving the problem in your head?
Why not write something down instead of remembering it?
It makes evolutionary sense to use "outside" help instead of having the brain do everything by itself. It's much more efficient that way.

You can of course debate these points as long as you like - they are by no means watertight ;-) - but what I'm trying to get to is this:
c) the Brain doesn't care about the bodies boundaries

"We" normally have the strong feeling to be inside our bodies.
Metzinger and others have shown that this feeling of "I" can be transferred to just about any place you want.
You can swap bodies with another person within a couple of minutes.
I myself had my hand "replaced" with one made of rubber which felt really weird - and that took just 20 seconds or so.

We also know that tools are quite easily and readily incorporated into the body schema - walking sticks, surgical tools and what not become parts of "us"; and if you want to speculate - sometimes even emotions and feelings come with that (just look at how some people feel and talk about their cars).

And here's why this is important:
the artificial boundary between "us" and the world simply doesn't exist.
We are part of the environment - and our surroundings are part of us.
We act on our environment - but also react to it.
And: most times we aren't even aware of how our environment "makes us do things".
As an artist I know how weird it can be when you are forced to take pictures like this ;-)):

Marketers, Magicians and others have known this for a long long time - and make a pretty good living off it.
Psychologists are just starting to unravel these complex relationships and describing what happens inside the brain when we encounter such situations.
Just read any book like "How we decide" and you will understand what I'm getting at - or watch Richard Wiseman's videos on YouTube.

Now you might think - as I did for a long long time - how is that helping me understand chronic pain - or even better: how is it helping me in treating chronic pain?
The answer:
d) computation can take place anywhere

Let's repeat:
a) Brains are lazy
b) Brains take all the help they can get
c) the Brain doesn't care about the bodies boundaries

If a+b+c are true - then d also has to be true. ;-))
The Brain doesn't care where the solution to a given problem comes from - as long as it's there eventually.

Just look at phantom limb pain:
using a Mirror Box a lot of people can achieve a significant reduction of pain within a few minutes.
The Brain has a problem - it tries comparing different sources of input and output which don't fit together (it has an unsolvable computational or information processing problem); by using a mirror "you" transfer this problem to the environment.

By doing this you are "reframing" the problem - making it easier for the brain to do it's work.
So part of the overall computing process now happens outside of the body and out of the brain.
The mirror image of the moving hand is like a computer moving ones and zeroes around.
It's all just information - which in itself is completely meaningless without context.

I could go on about this for a week or so ;-) - and maybe I will at a later date - but for now I want to leave you with this:
the treatment of chronic pain hinges on the fact that we - as therapists - have to find a way to make it easier for the brain to deal with the situation at hand.
By transferring the problem to the environment we reduce the complexity of the problem - make it easier to solve - and the Brain can stop creating pain.

Just look at how little help a toddler for example needs when learning to walk:
his or her gait pattern without help is often pretty unstable - but even the softest touch suffices to make it much more robust. All your one finger touching his hand does is provide him with input; the brain doesn't have to compute a problem in 4 dimensional space anymore (don't forget the importance of timing!) - but it can reduce the problem to a 2 or 3 dimensional one.
Let me rephrase: your finger is not providing physical support - but informational support only - telling the brain "Look - just treat this part of space as a constant - because it's as stable as the surface this body is walking on".

Get it yet?
Don't worry - I didn't either.
It takes a while to sink in. ;-)

This is the hard part about the science of embodied cognition - getting your head around the concept of you not actually being where you think you are.
The illusion of having this egocentric worldview is so strong and so pervasive that we just can't override it.
But if we look closely enough we can spot it out of the corner of our eyes. ;-)
Like Douglas Adams wrote in the Hitchhikers Guide: flying is easy - just throw yourself at the floor and try to miss. ;-)

In order to show you how this actually looks when applied to patients I will talk about sensory discrimination training in another post.

There really is no spoon - Part II

2009-01-01T10:21:00.000-08:00

The starting point is of course our minds.
The mind is our way of interacting with the outside world - and also with our bodies. Being the artist that I am I postulate that there really is no difference between the two: our bodies (yes - even the one you feel you inhabit) - are the same as the outside world.

For me - in terms of the "Theory of Everything" - our bodies and the outside world are one and the same thing. Why? Because our bodies don't have fixed boundaries. Our body schema is flexible - enabling us to incorporate tools, peripersonal space and other things.
And once something is incorporated into our body schema we show the same stress response as if our real body were in danger.

And yes - you even can swap bodies or faces in a few minutes if you want to.

I don't think this happened "on purpose" - but is simply a happy/serendipitous effect of us being able to use tools. It's just one of the mechanisms we can exploit if we want to.

However - I also wonder about the effects it has on us - even if we are not consciously attending to them. As we have shown the brain is remarkably plastic - it changes all the time. And since the mind is a product of the brain it also changes with it.

So if our body schema is changed by tool use - what happens to our minds? For those who want to rant about the Internet - remember that language is an invention and a tool also - albeit without an external power source.

The Alphabet is a tool any of us uses on a daily basis - and yet we don't think about it that way. But it has to have an effect on us - as we can see when scientists compare peoples way of thinking that are from different cultural backgrounds.

"You" are changed by where you were born and where you live and what language you use. Twins raised apart show strikingly similar behavioral patterns - I wonder what would happen if you compared twins that were raised apart - one in the US and the other one in China for example. My guess is that only then could you clearly show how much genetics (really) influences a persons behavior.

Our brains use a lot of tricks, shortcuts and even lies to present a coherent world to our minds - and we can exploit those weaknesses almost at will. That's very useful in treating chronic pain syndromes as shown by mirror therapy.

But what about all the drawbacks this haphazard way of creating the world has?
What effect on the mind has sitting in a chair all day long? I'm not talking about back trouble here - but by not moving we are changing our cortical maps. And the mind is based on those maps. So what happens to the mind - your way of thinking - when you sit for long periods of time?

I know from my own experience that I can't do any serious work when sitting in my otherwise excellent Stokke Gravity. It is the best piece of furniture I have seen in my entire life - comfortable, well made, sturdy, gorgeous to look at - but I can't think when in the sitting position.

For me pacing around is the best way to come up with new ideas.

This folks is the riddle of the embodied mind. Our minds are based on our brains and bodies - and what you do with one of them has an effect on the other. Which one has which - well - that's for you to find out.

The only thing that seems pretty clear to me so far is this: as you exercise your body - you also have to exercise your mind.

And I'm not talking Sudoku here - but "deeper stuff" like focusing attention, meditation and the like. As one improves - so will the other. Attention in itself seems to be the most important part - but that requires a whole series of postings on itself.

There is no spoon - Part I

2009-01-01T06:23:00.000-08:00

A while ago I did a series of postings about pain and about mirror therapy for phantom limb pain and other chronic pain syndromes.

The good news is that all of the information contained in that series of articles is still as accurate as when I wrote it - and is a good starting point for most laypersons, therapists and those who suffer from chronic pain and want to try a new form of treatment.

From the feedback that I got it is clear to me that I did a good job of explaining the very often difficult science behind it and made it accessible and understandable for everyone.

However - as an Artist and Visionary (I took a test that said that I am both) ;-) my brain refuses to stop thinking about that stuff.
And that's what I have been up to for the last year or so.

In order to go even farther - to develop even better and faster ways to treat pain we have to construct a "Theory of Everything" as I like to call it - because only then will we be able to see how we can exploit the weaknesses of the brain even more to our advantage.

The good news: there is enough experimental data available from a lot of different fields that we can start to construct such a theory. The bad news: it's a lot of different disciplines from which I have to "borrow" from and try to integrate them into one comprehensive overview. And new stuff keeps cropping up all the time which makes it hard to keep up with all the new input.

In the past I've made a few pretty wild guesses (based on the data available at the time) - and most of them were shown to be true. See for example my description of how to treat chronic pain in paraplegics (Yahoo Group Supertraining, Message 29357).
My idea of using visual feedback in treating chronic low back pain by showing the patient an image ofhis back on a monitor is now undergoing trials in Australia.

So I want to start this series with a few questions that are on my mind right now and that show where my "Theory of Everything" is heading at the moment.
And - since I am an Artist - I don't recognize authorities or self-made boundaries I'm going to sound pretty weird at times. ;-)

Here we go:

- We are still accustomed to thinking in terms of influencing the real body when treating patients. However research on Phantom limb pain has shown that there is a virtual body which our brain constructs. The simple solution to phantom limb pain turned out to be not to treat the real body - but the virtual one.

Something similar happens in CRPS - the symptoms we see in the real body are just that - symptoms. The real disease is in the brain - in the representation of the affected limb - a software error so to speak. And treatment that tries to correct that software error leads to automatic changes in the body. We simply have to tell the brain what we want it to do and it does all the things necessary - like increasing blood flow and so on.

In the talks I give I always try to teach my students to shift their perspective from a hardware based model to a software based one.

Now - what if we took this idea even further? What if we applied this model to all forms of pain? What if instead of: "When I want to move my arm I tell my boy to do it." we were to say "If I want to move my arm I move my virtual body - which then sends out a signal to the real body to replicate the movement."?

This might not sound like a big difference - but in terms of rethinking movement and movement control it's huge. Remember that the virtual body can be quite different from the real one!

What happens when a distorted virtual body is simulating a movement that the real body can't replicate because there is a limb missing? Phantom pain is the answer.

Now take chronic low back pain - and you can see the same mechanism at work - the cortical field of the low back is enlarged - and yet the real lower back stays the same. Pain is the result.

Giving up the idea of treating/working with/even having a real body is difficult - one of the drawbacks of having an embodied mind - but I think it's crucial for us to "just let go" if we want to develop new ideas and treatments.

- Placebo. Placebo is a fact. There are enough studies out there showing that it works - and works really well.
And yet - the mechanism of action is as yet unknown. Really?
Again - think about the difference between a virtual and the real body. What if the placebo (be it a procedure or a pill) - is simply becoming a "piece of software" - and the brain tries to simulate it's effects on the virtual body - thereby changing the real body.

The brain has to represent the outside worlds so our minds have something to act upon. This is where the mirror neuron system comes in. So while the brain simulates the interaction with the placebo it accidentally changes the real body in response - setting free endorphins and the like.

This of course is just a rough idea at the moment - but what if placebos manage to - once again - fool the brain by using this "trapdoor"? The mirror system wasn't "meant" to be there for placebos - but for understanding others/empathy and so on - for all the stuff you need to be able to do when living in groups. It seems to me that placebos exploit this weakness of our brains quite efficiently.

- Environment changes behavior. Lasting behavior change is difficult. We are after all creatures of habit. But again - what study after study shows is that the environment we find ourselves in actually determines some of our behavioral responses.

We are not "in charge" - but are influenced by what and who is around us. And yet - our brains still hold up the illusion that "we" are in charge and give us the feeling that we wanted to do this or that. The short story is this: if you have identified a behavior that you want to change - don't try to change it directly - but try to change the environment in which it manifests itself.
Remove the "cues" if you will that "make your brain do things automatically" - and you will succeed far more quickly and it will last.

As I've written before - starting an exercise regime is often quite difficult - because there really is no spare time left in a day. By identifying "empty time" - time that is spent doing meaningless tasks you create time in which to exercise.

And just to make clear that it works really really well: I've been going to the Gym for a year now - doing 3 sessions each week (1 hour each) - and have lost 45 pounds. Just as I said I would. And I'm not going to stop there ;-) - because by now it's turned into a habit - like brushing my teeth.

- "Me". Our brains create the illusion of "I" in order to .......? What is a feeling of "Me" good for? Based on the fact that our environment changes our behavior quite dramatically I think we should take a closer look at the concept of "I".

What if we really are like worker bees - mindless robots following a few simple rules in order for the queen to survive? Would it make us less happier? Look at the people around you: seems to me that most of them are unhappy anyway.

Since this feeling of "I" is so strong I think it's pretty much impossible to try to imagine a theory without it - the drawback of an embodied mind again. But if you look at the Hardware/Software approach I think it's one well worth pursuing. What if "we" are really just cogs in the machine being made to think we actually have a say in the matters of what the bigger machine does?!

One of the first steps in this direction is the Biopsychosocial Model. It recognizes that we as people are a part of different environments and groups - and looks at what influences us.

- Another trapdoor of our minds. Here is more evidence for my hunch that "we" don't really exist: you can be made to swap your body within a few minutes. One can - by visual trickery and exploiting our sensory system - be made to experience another body as one's own.

We can also include objects into our body schema quite easily. "We" don't really have fixed boundaries. What we think of as our body is really just a constantly changing "sphere of influence". This helps us in using tools.

It was never "meant" to be more than that - but this is the beauty of the brain: you can use all these mechanisms that evolved over time and do some crazy stuff with them. As you can see our bodies aren't real in any way - you can change them, make them bigger or smaller, give them extra arms - even swap bodies completely.

What if the same goes for our minds? What if our mind is just a tiny part of a bigger (hive) mind? After all - culture looks to have a mind of it's own sometime. The culture you grow up in shapes you and your brain - and you become part of it by reinforcing the same behaviors and cultural norms. You become part of it. And that becoming part of it is manifest in your brain.

And since your brain creates your mind it changes you. If you grew up in a different culture you would be different and have different ways of thinking and acting. But you'd still feel as if "you" were in charge - which you are quite clearly not. I wonder what would happen if you got rid of the "Me" module in your brain and would start to experience yourself as part of something bigger - a hive mind.

I sometimes get the feeling that there are people who either have achieved this or are close to it: people who are driven by the need to do something to benefit humanity as a whole. (or it's just the endorphins released by doing something good which you can get hooked on too). Either way - I guess this approach would give us some pretty far-reaching insights.

As I've said - these are the questions that keep me up at night at the moment. ;-)
The difficulty in making progress is that the feeling of "I" is so strong that you can't run a simulation in your head without the "I" part being central to it.

We'll see where it leads as more evidence is produced in labs around the world.
The following postings will show different aspects as the relate to my development of the "Theory of Everything" and present proof that most of my crazy ideas are based on science and solid facts.
Have fun! (It's just a ride)

Relax

2008-02-13T12:14:00.001-08:00

Regular Readers of this blog will have noticed the absence of new posts during the past couple of weeks.

Well - the blog was never intended to be updated regularly.
I always wanted to create some kind of "database" for interested therapists and patients alike. So you can always go back to the archives and start exploring. ;-)

There are a lot more topics I'm working on - but between "regular" work and photography there is just too little time left at the moment to ensure that new articles would adhere to the standards I have set for myself.

To make it official: I'm taking a break from blogging. I guess I should "be back" in a few more weeks.

If you find yourself a bit overwhelmed too - just look at this picture for a few minutes and you'll be relaxed like never before: ;-)

Interview with Diane Jacobs - Part III

2007-12-29T07:56:00.000-08:00

Part I is here.
Part II here.

Matthias:
"Gandevia and others have shown that by displacing skin - for example at the fingers - gives the patient the illusion that the finger has moved. The same thing happens when you vibrate tendons - depending on the context people think their limbs start moving. It seems from this line of research that our brain constructs a Virtual Reality Simulation of the body - a virtual body as it is often called. Do you think that the brain regards the virtual body being real and that problems in the real body (only) arise because of discrepancies between the virtual and the real body? What I mean by this is: the brain tries to adjust the real body so that it fits the virtual body?"

Diane:
That is a good testable treatment construct, I think. Butler has been thinking along these lines as well.

Matthias:
"What can patients do on their own to keep their virtual body flexible and healthy? What are some of the things you yourself do in everyday life to keep it fit?"

Diane:
Well, everyone knows that pain can arise when the real body gets impacted, jolted, injured as in a car accident, etc. Most people do not realize pain can arise through ordinary daily habits. I usually ask patients what their "default" positions are, the positions they adopt while being sedentary.

These positions often leave lasting impressions on the nervous system. For example, most people relax in the evening, sit with a leg crossed over the other. Many people always cross the same leg, have for years, never the other. Or they will pick a corner of the couch to watch TV from, and tuck their legs up to the side - always the same direction. Or lean on one elbow - always the same elbow.

I once treated a woman who had an enormous dint in the side of her leg from her other knee pressing in. You can learn to spot the sedentary habits from the impressions they leave on the actual body! But think what this must also do to their virtual bodies after awhile.

I make people aware of the need to observe themselves at home, become aware of their default positions, change them. I explain it simply - let them know that nerves need fed evenly from all sides or eventually they'll set up a distress call.

I don't teach "exercise" anymore, instead I teach sensory awareness, i.e., anything that will change sensory discriminative input into the neuromatrix. Change the relationship to gravity - lie down on the floor. Attend to breathing. Stay focused on the breathing and lengthen out an arm along the floor, see how it feels.

Do telescoping movements instead of stretching. Shorten and lengthen. Breathe. Feel what parts are trying to help and which ones feel as though they don't help, or resist. And don't worry about trying to make them do anything they can't seem to. Stop trying to override everything, just notice things, let them be, let them change by themselves, but keep checking on them periodically.

Do not cause more pain.
Practice moving without pain, practice what you can inside the comfort zone - there's lots to work on without trying to push the boundaries. Wait. Do small amounts frequently. Think of this work as feeding the nervous system.

Like a very young and cranky baby, it cannot absorb very much at a time. It needs your help and caregiving and attentiveness and feeding, but it needs small amounts frequently to turn itself around and thrive. A big "meal" once a day would be counterproductive, to say the least.

I use the example of learning to ride a bike - here's a complex motor skill that requires about three days to learn. All that's required is repeated exposure to the task, practice. Nothing is going to happen until that exposure has made its way all through every part it needs to go.
Patience and repeated exposure is all that is required.

Suddenly, on about day three or four, the task is accomplished - suddenly, the brain has figured out how to help your body achieve balance and coordination sufficient to ride a bike, and it's without effort. It's the same for learning to move without pain.

Matthias:
Diane – thank you very much for sharing these fascinating insights!

I hope more people will be inspired by your example.

Interview with Diane Jacobs - Part II

2007-12-28T07:50:00.000-08:00

The first part of the interview is here.

Diane:

From that point on I became an ectodermalist. I deliberately gave up worrying about muscle function, joint alignment, posture, all that stuff. I became mainly interested in helping people downregulate pain, manually, but since then I've focused my efforts on learning all I can about that first layer that is contacted in manual therapy, about how it reads contact from another nervous system.

This has taken me into learning about the brain faster than anything ever did previously. I've read all I can lay hands on about pain, how the brain works, how it evolved, how it produces movement, pain, and perception as output, how it "feels" its environment, how it constructs strategies for its own survival and for that of its "organism". As fast as I can learn, more info is being produced. Is it possible to ever know enough?

I've learned about the cutis-subcutis layer, how it regulates homeostasis, about the importance of the cutaneous nervous system in this regard, how although it doesn't innervate "muscle" it is still "motor" in that it has autonomic efferent function as well as afferent sensory function.

I've done a dissection of the arm, to learn how the underlying cutaneous nerves (which run parallel to the skin) send off many mechanosensitive disseminating twigs that embed into skin from below, via tubular skin ligaments. I was allowed to photograph this work, about which I'm currently writing an article.

All this sensitivity built into skin is adaptive, and can be construed as the brain's own sensors, feelers, into the environment. Touch skin in a therapeutic context and it is as if you are touching someone's brain, on many levels. Knowing the levels and knowing how to help them downregulate themselves properly is the whole knowledge base that helps manual therapy make more sense.

I'm involved in a study to determine the effects of a completely nervous system based form of treatment, which I have called "dermoneuromodulation", on pain. It considers the cutaneous nervous system closely, tries to move it carefully according to the principles of neurodynamics.

I am still in the process of de-programming myself from all the mesodermalist learning I took on, but have made a lot of progress. Instead of viewing manual therapy as something I do "to" someone's body, I see it now as interaction "with" someone's nervous system.

Matthias:
"From what we heard so far - it seems that your approach could be described as helping people heal/help themselves - pointing their brain in the right direction. It seems to me that this dermoneuromodulation is different from other treatment methods because you emphasize downregulating much more than others which are more about adding strength here, increasing mobility there and so on and so forth. Your treatment is more about removing obstacles so that the brain/body can heal itself. Would you agree with this assessment?"

Diane:
I would agree with you in general, especially the part about obstacle removal. But I wouldn't say my treatment does this - when the brain is ready to change its output, it does. That's all.
The whole illusion that I, the therapist, create change in someone else's nervous system, is fantasy. I like to think of my work as pointing out possibilities to the patient's brain.

I feel like I just hold up a flashlight while the patient's brain gets busy fixing the "problem". :) I think my presence is necessary so the nervous system can get a good "read" or "fix" on some body part, but it does all the heavy lifting - my role is to feel the changes as they occur.

Matthias:
"It sounds to me that by using skin and it's cutaneous nerve system you are in a way talking directly with the patients brain - trying to establish “first contact” so to speak. What role does the patient play during this treatment process? What are your instructions to them? Should they try to move the part of their body that is being treated? Should they just observe?"

Diane:
The patient plays an observing role, but it's a lot bigger than it sounds: I ask them to let me know immediately if they experience any discomfort. Most people willingly take this task on - it not only gives them a tiny, manageable, focused task to do, it reminds them that they have charge of that all important "locus of control" - they become treatment manager/gate keeper, in a way.

Several other important objectives are met. They immediately realize they must be engaged in the process, mentally. They came in thinking it was I who would do all the work and they would just lay there, but now they realize it's about them focusing, breathing, staying in the process. All this from just one simple instruction - "I can't 'feel" your body the same way you can.

I want you to tell me if you experience any discomfort, because there is no point in reinforcing any pain pathways - that would be completely counterproductive - and besides, if you are experiencing discomfort it will be harder for you to relax and let your nervous system change itself."

Then I ask them to feel their breath go past their nose, on the way in, and on the way out. If I have a rapid or shallow breather to deal with, I ask them to breathe out for twice as long as they breathe in. That's about all.

It's like learning to meditate. The outward mechanics are rather simple, but a lot of processing goes on. I let them figure out how to do that themselves. Our connection is through the skin, and they've been instructed to tell me about any discomfort they might feel. Some people go for complete silence immediately. Others like to stay in more verbal contact.

I let them decide what level of engagement with the process they want - it's up to them, and I realize they need to establish rapport with me in their own time. As long as they can process something, dip in and out of the process even, it will be fine. Lots of people give me a running commentary of what they are sensing.

A useful metaphor is skin diving. Skin diving is the process. On one level it looks like I'm the one "doing" the skin diving, but in reality, I'm the one left on the boat managing the lines, staying alert to danger, and the patient is the one doing the dive, for the first time perhaps, diving right into their own processes, sometimes scary, sometimes wonderful, but it is they who have to do the "work", exploring, bringing up the sunken treasure - which turns out to be a fleeting realization that they can in fact move some part without pain, if they like.

They realize they have an option. It's a lot like mirror therapy I think. Instead of accessing a visual part of the cortex to convince the motor map that movement is possible, the kinesthetic sensing part of the cortex (or perhaps subcortical maps as well) are accessed somehow. And most patients will choose freedom to move over pain.

A space opens up, an opportunity to move without pain, and the patient accepts the possibility as their new reality. This decision-making is done well back of their "ordinary" decision-making capacities - it's quite automatic, although they get to be aware of it in the moment.

Certainly they are free to move in the moment if they would like, but usually I ask them to sit up periodically to move, see if they can move more easily. Most of the "movement" during treatment is palpable to me - it feels like physiology - little pulses start up then fade away, elongations occur, muscles twitch or feel as though they gently writhe,... small things that signal something rather large and non-conscious is happening below the surface.

Interview with Diane Jacobs - Part I

2007-12-27T10:21:00.000-08:00

Some of you might already be familiar with Diane Jacobs from her blog Humanantigravitysuit or from the Teamblog Neurotonics where we share our views on certain topics.

I asked Diane a while ago if she would like to do an interview – and I’m happy to say she agreed.

She has over 35 years of hands-on experience, reads everything she can get her hands on and is a devoted student of the human body and it’s inner workings.

She has developed her own approach to treating pain and movement dysfunction – called Dermoneuromodulation.

By showing how she developed her style and treatment over the years I hope others will find some inspiration.

Here’s Part one:

Matthias:
Diane, glad you agreed to do this interview.

Please tell us how you came into the profession and what factors shaped your career:

Diane:

I entered PT school (a diploma program at U. of S.) in 1968, at age 17. I entered into the program hoping to be taught how to use my hands to help people rid themselves of pain. Three years later, I was a graduate with a license, and lots more growing to do. The hands were trained for a lot of things, but helping to relieve pain somehow had escaped inclusion in the curriculum.

The first decade out of school was mostly about growing up, learning to be independent. I worked in hospitals, took university classes frequently, figured my adult self out. I played by the rules and enjoyed life. I still wanted to learn to use my hands to help relieve pain, but hope was fading that I'd ever learn to do this within the profession of PT.

Around 1983 I went to a workshop taught by an osteopathic physician. There, I learned techniques for handling spinal dysfunction and other kinds of pain, muscle energy technique and positional release. I thought I was the luckiest person on the planet, bumping into this teacher.

Based on this single workshop, I pulled up my life in Saskatchewan, moved to BC, to be closer to the manual therapy school he taught at. For the next 20 years, on and off, I attended his school and became very good at using the techniques taught there. I began attending orthopaedic training workshops taught within the PT community, but dropped out, having lost interest - they were about learning to manipulate joints, and I was decidedly uninterested in pursuing that direction. The osteopathic techniques were more clinically interactive and very helpful to people.

By now I had my own practice, successfully treating all manner of patients with these gentle techniques. There was still something missing however - the treatment constructs were very biomechanical, and I was ready for more understanding.

Enter David Butler in 1998. He spoke a new fresh (to me) language - suddenly I was hearing all about physiology and brain and peripheral nerves. Peripheral nerves? They can "hurt"? This new layer of information and the emphasis on careful handling compared very favorably with the techniques I'd been using - I realized that all along, they had been "neurodynamically" friendly without the originators' ever having known the first thing about neurodynamics or any other concept about the physicality or structure or preferences or sensitivities of nerves in the body.

The techniques had simply been developed in concert with patients with treatment constructs tacked on after the fact, treatment constructs that didn't make any real sense because they were (archaic to me now) bio-mechanical, joint-based, structure-based (e.g., bones, fascia) - if they involved consideration of the nervous system at all it was a convoluted construct involving some sort of influence of treatment on muscle innervation, as if skin didn't exist at all.

Matthias:

Please explain why skin is so important in the approach you developed?:

Diane:

I realized no one seemed to care about skin. No one cared about the fact that all manual techniques are applied through skin. That the cutaneous system reads every kind of handling first. That the brain reads every kind of handling first. Practitioners only seem to care about what is underneath skin. This suddenly seemed ludicrous to me.

Then something else clunked into place, cognitively - a lot of detailed study of embryology. I remembered that skin came from ectoderm and so did the brain. At the manual therapy school all this embryology was taught, yet the techniques themselves were taught from a mesodermal or structural perspective, not from a nervous system perspective.

For me, cutaneous innervation became the transition; it is still structure, but helped me bridge the techniques I loved to do into a context that made much more sense as to why on earth they seemed so helpful. I realized they were brain-friendly - that when performed expertly, with attention in the moment to every detail in the moment, not in any zombie-like or mechanical fashion, but slowly, with feeling, they helped the brain down-regulate pain.

Matthias:

I hear you!

The focus – at least here in Germany – is still very much tissue based.
Neuroscience isn’t mainstream yet.
I want to point out to all the therapists out there who read this that they don’t have to give up their favorite techniques – just that they have to look at what they are doing based on the bigger picture.

If you are manually mobilizing a joint – you have to touch the patient – there is no other way to do it. This fact is sadly overlooked in most approaches.
By thinking in terms of altering nervous system input you can achieve miracles since the brain takes care of the rest.

Again: use what you have learned – but change your thinking about why you apply it and how!

Play As If Your Life Depends On It

2007-12-22T10:36:00.000-08:00

That's the title of a book I bought recently. I haven't read it yet - but the title alone is worth it's weight in gold. ;-)

I don't know if there is a proper definition of play and playful out there - but here is mine:
"Play is the joyful exploration of oneself and one's surroundings/environment" (this also includes interaction with said environment).

I want to stress the joyful aspect of it here. If you are doing things because you love to do them - then that's one of the strongest and best motivators out there. And motivation means that the sky's the limit. ;-)
(Fear by the way is an equally strong motivator - unfortunately accompanied by a lot of detrimental side effects).

Why are babies and children able to learn so much so quickly?
Because they are motivated, hardwired to learn and have fun exploring everything around them.

If they are interested they focus intensely on one thing - and one thing only. They have no problem whatsoever trying hundreds (?) of different ways to interact with objects in their environment. They are exploring things from perspectives we - as adults - would never think about.

Who would voluntarily go inside a closet and pull the door closed behind them?
Who would sit under a table and declare it to be a cave?
Who would insist on wanting to lie in the trunk of the car on the way home? (I did once - and my wish was granted) ;-)

By not doing things like that - even simply lying on the floor reading a book for example - we forgo certain experiences. Our interaction with the environment becomes "dulled down" and repetitive.

Once you try a couple of new things you suddenly realize how "liberating" and refreshing they actually can be.

Give it a try - lie down on the floor and read a book down there. Or draw something - anything.
Compare that to your favorite spot on the couch or in your favorite chair and see how much more feedback the floor provides.

I'm not saying that this particular exercise is joyful - in most cases it even hurts a little because you are simply no longer accustomed to it.
But it's one of the best ways to get quick feedback from your body.

Now think of you going to the gym every week - doing the same exercises over and over again.
Not really inspiring isn't it?

Try to adopt a playful attitude here too: do the exercises differently - with your eyes closed for example. You'd be surprised how different things can become when you change them even a little bit.

There are restaurants now that have no lights. The staff are blind and the food is served - and eaten - in total darkness.

Since taste is integrated with our sense of vision the food tastes completely different.
Shake things up to keep them interesting and fresh. Brains like novelty!

As for chronic pain: in order to re-wire the brain you need attention and motivation. Those two ingredients are the best recipe for quick changes.

So find movements that you like, ways to do things that you like - set the mood - and go play!

Mirror Box Therapy - Part VII

2007-12-16T10:52:00.000-08:00

F.A.Q.

This section tries to cover any question you might have and should serve as an additional resource so that the experiences people have with this kind of therapy can be recorded and shared.

1) Are there any known side effects?

None have been reported yet.
Things that can happen - depending on the condition are:
Lorimer Moseley reported a patient that was so distressed seeing the amputated limb move again that he had to withdraw from treatment.
Another interesting phenomenon is Dysynchiria - if you touch the unaffected limb and watch the reflection pain is felt in the affected limb.

2) How long should the sessions last?

Since you have to focus your attention on the treatment 10 minutes at a time are sufficient. Try to repeat it several times a day for a few weeks.
There are huge differences between individuals regarding how fast they respond.

3) Are there commercial suppliers of mirror boxes?

Yes - you can order them here and here for example.
Or you can make your own by following these instructions.

4) What do I do during the session?

If you have pain in your arms, hands or fingers try moving them in any way possible. Pick things up, count coins, do whatever you can. Vary the movements from simple to complex. And above all: watch what works best for you.
Jeiseas Blog is a great resource - see how she uses it. What works for her might also be good for you.

5) Which therapist should I see for mirror box treatment?

This is a tough one.
The treatment was developed by a Neurologist and is used (and expanded) by Physiotherapists, MD's, Psychologists and other professions.
In effect the treatment belongs to you - the person in pain.
Any attempt to bring it under the domain of only one profession is - in my view - completely nuts!
By explaining it in this series I hope you are able to give it a try yourself.

6) Which conditions can be treated?

First the obvious ones: phantom limb pain, CRPS, RSI.
Then the not so obvious one: central pain in paraplegia.
And last but not least those problems that can be treated by applying the principles of feedback therapy: low back pain, tinnitus, anorexia (?!), fibromyalgia.

Mirror Box Therapy - Part VI

2007-12-03T09:51:00.000-08:00

or: Outlook - Possibilities - Thoughts

OK - our brains are built to predict the future - let's see if I can help that along. ;-)

Blakeslee - in her excellent book - has reported that there are preliminary results that viewed the problem of Anorexia from a body map disorder point of view. What if people with anorexia "just" have a different body map - one that is much much thinner than their real bodies.

Easy: they feel extremely uncomfortable in their own bodies. I imagine it like your whole body being numb (think of the effect you feel after you visited your dentist - now only include your whole body).

The only way to make the felt image and the actual image fit is to starve yourself - in 20% of cases even to death. That's how strong this urge is.

The thing we have to recognize about emotions and the urges they produce is that they are strong motivators - they "make us do things". And only when we have satisfied whatever the emotion tells us does the urge go away. Viewing pain as an emotion like hunger and so on makes it much easier to grasp what's it all about.

My best guess is that eventually all body dismorphic disorders will be recognized to really be "body map" disorders and be treated accordingly.

(I know that pain is not a real emotion - it's much more than that. But some of the effects it has on us and on our behavior are very similar which makes it easier to talk about it.)

Another very frequent condition where feedback therapy shows good results is tinnitus.
Again - peripheral thinking (i.e. in terms of damaged structures) hasn't amounted to much progress being made.

Now - thanks to brain imaging we can see that tinnitus is the same as phantom limb pain only for our sense of hearing. The auditory cortex where sounds are mapped becomes disorganized - creating random noise. By re-training the auditory cortex - as Herta Flor and Colleagues have done - having the patient distinguish different frequencies and so on - the symptoms can be markedly reduced.

Another treatment that is able to alleviate such symptoms is TMS (transcranial magnetic stimulation) which shows even better results.
One clinic in Germany at Regensburg University is working with this technique. And on a sad side note - largely unnoticed by the medical establishment as yet.

Migraines - with aura - are yet another field where neuroscience has found an identifiable cause - quickly spreading cortical depression. And the easiest way to describe treatment I have to think of the term "re-booting". It seems that a few neurons go haywire - causing others to join in. By zapping those neurons - which are located in the visual cortex - you can stop the effect from spreading.

A handheld device is currently undergoing final tests and should be on the market soon.

As for other frequent conditions:
focal dystonias, writers cramp, jips in golfers, RSI, .... are all due to some form or other of the map areas becoming deformed, fused or altered in some unintended way. Treatment as I stated before has to re-establish normal maps, creating congruence between the VR program and the actual sensory information.

If you don't suffer from any of these conditions count yourself lucky.

Not only was treatment unavailable till now - since no real cause could be found sooner or later people were accused of the symptoms being all in their heads - which in a way they were - but as real physiological manifestations - not some unexplained "psychological" phenomenon.

Don't get me started on the harm that was done to these people by so-called medical professionals who are too lazy to pick up a book or medical journal once in a while and are too arrogant to question their own knowledge.

A much more common problem everyone has to deal with sooner or later is aging and it's accompanying aches and pains.
The best term for this combination is sensori-motor amnesia - which - as far as I can tell - comes from Thomas Hanna who built on the work of Feldenkrais.

What do "old" people have in common?
Their posture, their way of walking, their difficulty in looking over their shoulders (which makes driving a car dangerous), and so on and so forth.

Yet - with a little hands on treatment - they are able to regain a lot of their mobility within minutes.

How come?
Well - I see daily life as a constant struggle between adaptive and (cumulative) maladaptive learning.

Babies learn all day long. They learn a language or two or three, they learn social norms and customs by imitation, they learn how to move their bodies in thousands of different ways. After a while they become school children - and learning takes on more of a purely "mental" form - the memorization of knowledge. "Body learning", i.e. different types of movement aren't explored any more.

Now you might say that during the teenage years most people pick up a sport - and you'd be right. But it is one sport - with one specialized way of moving - and not a great variety of things.

After that you have a job - and if you are really unlucky it either involves sitting or doing the same repetitive tasks over and over again.

What happens when you either have to little movement (sitting) or too much small movements is that your body maps change. Add to that that the tissue becomes hypoxic and you have a recipe for disaster:
this body map change is accelerated by the presence of pain.

Now - before pain becomes "felt" there is already nociceptive information being sent to the brain which uses reflex responses to automatically adjust posture and such. Just watch people at the cinema - they are constantly shifting position to distribute the pressure from sitting over a wider area of the body.

Only when those mechanisms don't suffice to change the nociceptive input pain is produced.

These two examples give you an idea about what aging is:
it is the slow accumulation of changes in our body maps with the effect that we un-learn how to move bit by bit. This process is accelerated/aided by sub-conscious pain and automatic reflex responses (reflexes are stereotypical - that's why old people "all" have the same posture).

It's not because our bodies can't move freely anymore - the brain simply has forgotten how to send the appropriate motor commands.

The solution: life-long body learning. Feldenkrais, Somatics, Yoga, .... - all build on this.

It's a bit more difficult to incorporate this into daily life - but things like the Nike Free are a good way to start.

Those shoes really do help your feet to become alive again.

What are you waiting for?
Go do something now or I will send them after you: ;-)

Mirror Box Therapy - Part V

2007-12-02T04:30:00.000-08:00

or: Resources

I love the Internet - plain and simple.
All my life I knew there was something missing - till broadband came along and changed everything. ;-)

This collection of links is an ongoing project - feel free to suggest additional links, blogs, websites, ... in the comments or by email to matthias.weinberger(at)gmail.com

Medical Databases and Search Engines:
- PubMed
- HubMed - a much better interface than PubMed
- Google Scholar

Recommended Journals:
- Pain
- Neuroscience Letters
- Experimental Brain Research
- Neurology
- Brain
- Journal of Applied Physiology
- Journal of Neurophysiology

Videos:
- YouTube
- SciVee

People:
- Ramachandran
- Herta Flor
- Lorimer Moseley
- Candy McCabe

Products:
- NOI
- Mirrorboxtherapy.com

Blogs:
- Diane Jacobs
- Neurotonics
- Howtocopewithpain - including a monthly pain blog carnival
- Psychology of Pain
- David Butler's blogs: one, two, three
- Michael Merzenich
- Deric Bownds`MindBlog
- BPS Research Digest
- MindHacks
- Mixing Memory
- The Frontal Cortex
- Healthskills
- Jeisea

Books:
- V.S. Ramachandran "Phantoms in the Brain"
- Sandra Blakeslee "The Body has a mind of it's own"
- Herta Flor "Psychobiologie des Schmerzes"
- David Butler, Lorimer Moseley "Explain Pain"
- Patrick Wall, Ronald Melzack "Textbook of Pain", "Pain"
- Alain Berthoz "The Brains Sense of Movement"
- Michael Gazzaniga "The Mind's Past"
- Jeffrey Schwartz "The Mind and the Brain"

Forums:
- NOI - the forum closed some time ago - but the archive is still there
- SomaSimple

Podcasts:
- Brain Science Podcast
- All in the Mind
- TED Talks

I thought about including a section about the most important scientific papers - but there simply are too many out there.
For those who want to dig into this stuff: start here.

Mirror Box Therapy - Part IV

2007-12-01T11:54:00.000-08:00

Feedback.

That's what the treatment of chronic pain boils down to: you have to send feedback - be it visual, tactile, auditory, ... to the brain so it can update the VR model. Only if the model and the corresponding motor command generated by it and the information from the external sensors matches up will the pain stop - very rapidly as several studies have shown.

Now - the really great thing about any type of feedback therapy is that the corresponding map which was altered in a maladaptive way starts to get reorganized while doing the therapy. That's what the studies report: during the first few training sessions the pain diminishes very rapidly - but comes back after a short amount of time (15 minutes,...).

But after the 5th or 6th session most people are able to get more lasting pain relief - and after just 3 weeks of daily practice most people can stop doing mirror box therapy altogether because the pain doesn't return.

This is all due to the positive effects of brain plasticity: the brain is able to re-organize very very quickly - provided it has the right incentive to do so.

As yet there are no long terms studies out that show how people with phantom limb pain that were treated with mirror box therapy have done over the years - this method is simply to new. I expect the first big trials to show up in the next 5 years or so in the wake of the studies done now at Walter Reed Medical Hospital with Veterans of the Iraq War.
That should give us an even better picture about what causes the process of maladaption in the first place.

My best guess is that initial pain (a painful limb that hurts before amputation) is the single most important factor - the brain learns the pain.
That's why amputations done where the limb was anaesthesized first show much better outcomes than traumatic amputations.

If you look at the case of CRPS - and to some extent after a stroke - you see another interesting thing:
the immobilization phase you have to go through after breaking a bone or suffering from a stroke tells your brain that - despite it sending motor commands to your limb - there is no proprioceptive feedback from the sensors in that limb.
If you can't move your hand because it's in a cast it can't send enough feedback to the brain.

So gradually over the weeks the hand map is adjusted - resulting in a limb that actually can't be moved even after the cast is removed. The brain has un-learned that the hand can move a great deal. And since the VR simulation in our brains is the basis for our actual perceptions and thoughts and feelings and everything else a lot of people describe their afflicted hand as no longer belonging to them.

An even more extreme example with different causes is the so called Alien Hand syndrome in which people don't recognize the hand being theirs at all.

What happens with the hand during CRPS - the swelling, osteoporosis and all the other stuff is secondary to the changes in the brain!

By using a mirror to give the brain visual feedback of an intact, healthy and freely movable limb re-organizes the map and symptoms vanish very quickly.
There are some preliminary results that show that even in stroke - at least part of the paralysis that results is not "real" paralysis - but learned paralysis - the brain just thinks that one side can't move any longer.

And even if that only accounts for say 20% - every bit of function you are able to regain after a stroke is better than nothing.

What sets CRPS apart from other chronic pain syndromes is that in addition to the hand map becoming distorted is that people aren't able to distinguish between a picture of a left hand and a right hand. They loose the sense of laterality.

This could be due to the fact that the brain uses the representations of the hands in it's internal model to construct laterality in the first place.

This would amount to the loosing of one of the models of the physical world that was established during childhood. Imagine yourself loosing your sense of gravity - one could no longer throw things accurately because you wouldn't be able to plan a parabolic trajectory - you would think that things always just fly in straight lines.

The NOIgroup Institute has developed a set of cards and a computer program with which you can re-learn this basic first step called Recognize.

If CRPS is in full swing however and sort of movement might aggravate pain.
That's why in severe cases you have to wait a little before you can do visual feedback therapy (mirror box).

The treatment in these cases starts by doing imaginary movements.
Those activate the same brain areas as actual movements - after all the brain does the same while running the VR program - the only thing that's missing is the actual motor command which is actively inhibited.

That way you can train the neuronal/mental circuitry which later will be activated for real.

As for areas of the body that have no limb like features - like the back:
you could have the patient lie down and point a video camera at his back and show him the image on a monitor.

But - as a few clever scientists have found out long ago - visual and tactile feedback are treated as equal in the brain.
Here finally the hands of the therapist come into play. ;-)

By touching the skin over the area you want the patient to move you can facilitate the whole process.
Once he has established motor control over that area again he is instructed to activate the muscles in that area every day so that the brain receives proprioceptive information from that area on a constant basis.
I advise some variation of primate grooming for home use: back rubs, brushes, whatever is available.

Regardless of which type of condition you have or want to treat:
the basis is always to send feedback about a limb or another part of the body to the brain (the comparator).

Feedback in daily life is important: remember how hard you had to hit the keys on an old typewriter?

Today's keyboards - especially the new one's from Apple are awesome!
Touch screens however are tricky because they don't provide any feedback. If the manufacturers were clever they'd introduce a very slight vibration - that would do the trick.

Mirror Box Therapy - Part III

2007-11-29T12:35:00.000-08:00

or: the bad part

As I've tried to explain: the maps of the body are what the brain uses to run the virtual reality simulation. And maps are plastic - to some degree.

Genetically every body map has 2 hands and 2 feet. Even when - through some defect you are born with only one hand! The map still says that there have to be two - and that is what the VR simulation represents. That's why people with one limb missing from birth still are able to feel a second "phantom" limb.

The brain doesn't care about reality since it regards the VR simulation as being reality.
It may take a while to get your hand around this - but trust me - this is what happens.

Let's have a look at this visual illusion:

Your brain - based on the models it has built over the years insists on seeing different sized tabletops. It just does. Why? Because the internal VR simulation is built on a model that says that illusionary perspective (fake 3D so to speak) means depth - even when - like on the monitor you are looking at - only 2D is present.

And so it decides to factor in this fake perspective and makes one tabletop seem bigger than the other.
This internal VR program can't be overridden (!) and is presented to you (your consciousness) - as being factual.
By the way: the tabletops have exactly the same shape and size - at least in"real" reality. ;-)

Or think back to a visit at the dentist when your cheek was anaesthesized: if felt bigger - much bigger - even when you looked at it in the mirror. Those sensory illusions are the results of the brain trying to make sense of conflicting information. It runs the data through the VR program and decides that the outcome - however ridiculous - has to be true.

Now for the really bad part:
if those maps - that form the basis for the VR program - are plastic - what about them running amok? What happens when something goes wrong and those maps change in a maladaptive way?
That's what happens in phantom limb pain, CRPS, chronic pain syndromes, anorexia, body image disorders, ...

Let's have a look at phantom limb pain:
here the real limb is amputated - but the map stays. It shrinks and adjacent map areas take over - but there is always a representation of the limb present. And the VR program is built on that. Watch someone who lost his arm slip - he still reaches out with his missing limb to steady himself.

Why? The VR program was built to save time - to enable us to react as fast as possible. If we didn't have something like it we could never regain balance. So it uses the basic blueprint (2 arms and 2 legs) when it comes to balance.
This invasion of adjacent areas has as an effect that people who lost an arm feel their arm being touched when you touch their cheeks - the area next to it.

A different thing happens in chronic LBP: the area starts expanding - probably as a way to increase spatial resolution as I suggested some time ago.
It invades other nearby area - that's why after a while - chronic pain start to spread. It doesn't do so by clear boundaries - there are no recognizable dermatomes affected - thereby making treatment more difficult.

This maladaptive plasticity is most probably driven by these factors:

1) lasting acute pain: pain demands attention and causes fear. Both are strong chemical reactions - probably accelerating learning in the map area (at a cost of course)

2) reducing of computational demand: the brain adapts to the pain - learns the pain to free up resources in the periphery. Hence learned pain. Herta Flor has done work in this direction.

3) favorable genetic disposition to develop chronic pain

So regardless of what happens behind the scene - either a shrinking of the map or it's expansion - pain is the result.
The most notable difference so far is that in conditions where no input exists the pain is often caused or ... by clenching or spasms whereas there is only pain and nothing else when the affected part is still there - as in LBP.

This is certainly a very interesting thing to go into - but has little to no effect on therapy as far as I know yet.

So why does pain occur?

Well - the brain does a good job with the VR program - an excellent job in fact; but there are times when it has to adjust the output that is produced by that program; this is especially true when we encounter new and unfamiliar situations.

Imagine yourself having lived in the desert all your life and then encountering snow and ice for the first time. Your brain can't anticipate what's going to happen when you step on that white surface - it has no experience what conditions it'll encounter - so it constructs a motor command anyway and checks the incoming sensory information on a regular basis to adjust the motor command accordingly.

That's why you are able to learn new stuff very quickly.
This is done by an area that we'll call the Comparator.

In the case of phantom limb pain however there is no feedback available. Not tactile, not visual, not kinesthetic. And since our brains can't just crash like a Computer it sends out a signal to a higher brain center to deal with the problem. It's similar to other emotions: they are produced by "lower" centers to inform the "higher" centers to please do something about them.

And that is it - the "secret" of chronic pain. It's a message from the Comparator saying "I can't make sense of this - the VR model is fine - but the feedback from the sensors doesn't match. Please deal with it - I don't care how and get back to me." (At least that's what I imagine is going on in a Woody Allen kind of way). ;-)

The solution: feedback therapy.

Mirror Box Therapy - Part II

2007-11-28T10:54:00.000-08:00

or: the good part

A bit of Science - the "how does it really work" bit:
our brains build models of the external and internal world.
You could say that we have a virtual reality generator inside our heads that tries to anticipate the consequences of action (it's own and others).

Watch a puma or some other fast predator in the act of catching prey:
the puma's brain has to factor in speed (it's own and that of the prey), anticipate the course the prey is likely to take so it can plot an intercept course (this bit is like Star Trek) ;-), factor in the weight of the prey (!) - otherwise the moment the Puma catches it it is thrown off balance, open the jaws just so - not to wide or it takes to long to close them - nor too little or you catch nothing at all.
Pretty complex huh?!

If the brain of a predator had to start from scratch every time the hunt is on it wouldn't be able to catch anything at all.
Decisions have to be made instantaneously - speed is of the essence. The same goes for the prey by the way - without the jaw thing of course. ;-)

So how does a brain build a model of the world and the body?

Well - watch any toddler sitting at a desk - there comes a time during development when they start throwing things off the table - over and over again. They aren't called little scientists for nothing - throwing things is their way of learning about gravity. By throwing something off the table and hear it hit the floor beneath they learn that gravity is a constant and they are able to measure it's effect because the relation between the time it takes to hit the floor they can estimate the speed an object has.

There are literally hundreds of different experiments you can see going on during the first year of life - the visual tracking of objects for example. Infants - even when just a month old - learn that things in motion usually follow a steady course. That's why they are able to follow a point of light or an object on it's path even when the object is hidden from view for a short time. This truly is amazing stuff!

Again nature and nurture are at work here: the neuronal structures are laid down automatically - it's hardwired into our genome to develop these skills - but nurture "exercises" and strengthens these connections.

If you don't have the right environment present at the right time severe deficits turn up - as in the case of cats who couldn't move and were thus blind. Vision is dependent on movement - otherwise the brain can't make sense of the electrical signals coming in from the retina.

Not only does our brain contain models of the external world (physics, gravity, acceleration, ...) - but it also contains a body schema by having maps of the body surface all over the place.

The most important (and accessible) maps of the body are in an area called S1 - the Somatosensory Cortex - which is the funky way of saying "piece of brain that receives input from the outer body shell - skin".

And it is these maps that other parts of the brain use to run the virtual reality program - they are the basic building block of our sensory perceptions - or pre-perceptions as it were.

Say your brain wants to know how it would feel if you were to lift the arm straight up.
It doesn't send an actual motor command to do this - it runs an internal virtual reality simulation of you lifting the arm. It even anticipates the sensory feedback it would get from the receptors in your joints and muscles about you lifting your arm. These anticipatory sensory events are called pre-sensations.

The brain relies so much on these pre-sensations that it often acts on them instead on what really is happening. "Online" sensory feedback is only checked once in a while as it were. I will do a series on this some other time because it's such an important concept in treating chronic pain.

That way the brain can do every movement possible without you actually having to do anything in real life. This saves huge amounts of energy and time. Like in the example of the predator catching prey, saving time is a key function of our brains.

Again - nature and nurture: maps are hardwired - experience during childhood refine the maps (think babies sticking their feet into their mouths).

The big finding over the past decade or so has been that these maps are plastic and change constantly (within certain genetic boundaries).
If you use one part of your body more often the part of the map that corresponds is getting bigger - think violinists. One of their hand maps is huge.
If they stop playing the maps shrink again.
This has been shown for other forms of practiced movements too - juggling for example.
We have finally found one physical correlate of the motor skill learning process.

Even meditation - "just thinking" - is able to change your brain. Specific areas show remarkable differences between trained and untrained persons. This should convince even the greatest skeptics that the virtual reality simulation inside our brains is much more than a simple simulation - it actually is what the brain sees as being the real thing - a weakness that we can - among others - exploit in treating chronic pain.

Mirror Box Therapy - Part I

2007-11-27T00:25:00.000-08:00

As stated in this posting Mirror Box Treatment was first described by V.S. Ramachandran and colleagues in 1995.

As always in the Sciences he built on the work that was done before him - he just happened to connect the dots. ;-)
There are some indications that even back in the 1920's or 1930's there was a German scientist who thought along these lines - but never followed through. Imagine how different the treatment of chronic pain syndromes would've been during the past 70 years if they'd started back then!

So how does it work?
Say you have one affected limb - be it that the limb was amputated or you are suffering from CRPS.
You put a mirror in front of you - put the affected limb behind the mirror so that it is hidden from view - the other one goes on front - and you start moving both in the same fashion.

>

You of course know that the limb that you see in the mirror is just a reflection of the healthy one - but your brain can't.
Vision is a very useful but notoriously unreliable sense. Just look at any visual illusion to see how easy it is to fool the eyes/brain.
This is one of the best illusions ever: rotating spiral.

After staring at the spiral for about 20-30 seconds look at the back of your hand!
Even if you know that there cannot possibly be movement there you will still see something crawling under your skin - your brain gives you the illusion of movement.
There is no way you can override this illusion. Consciousness - like it or not - is just a bag of tricks.

The brain thinks that the limb in the mirror is perfectly alright (even when in reality you lost it through an amputation) - sensory-motor congruence is re-established and the brain stops sending warning messages to higher centers of the brain - what we call "pain".
Somatosensory maps are re-modeled (which happens very quickly) - and the pain is gone (forever).
This is one the key points of this type of treatment: it actually changes the very structure of your brain! (Flor, H.; M. Diers & C. Christmann et al. (2006), "Mirror illusions of phantom hand movements. Brain activity mapped by fMRI", NeuroImage 31: S159)

This type of treatment has been tested over and over again - most recently at the Walter Reed Medical Hospital - and success rates are well beyond 80% - some even report numbers as high as 95%.
All that with a treatment method that costs a maximum of 20 Dollars and only takes a few weeks.
There simply is no easier way to treat these conditions.
And the best thing: you can do it yourself!

There are a few commercial suppliers of so called mirror boxes - all favor a different approach: some are collapsible, one here in Germany favors an occupational therapy approach so you can do more difficult hand functions, ....
Fact is: it's the basic principle behind the treatment thats key - by providing (visual) feedback.

How about bilateral problems?
Well - back in March of 2003 I proposed (on the Yahoo Group Supertraining, Message 29357) that the same principle could be applied to paraplegics who often suffer from central pain. The part of the body below the spinal lesion is often felt as being very painful. I proposed to put a mirror on top of a TV set so that the brain sees the reflection of the upper body - and have a video tape show a couple of legs walking. That way the brain might be fooled into thinking that the legs are able to move and the pain should be gone.

I didn't have the resources back then to do this experiment myself - so I described it to Dr. Mel Siff whose wife is paraplegic. Unfortunately before I could describe to them how to set up the experiment Dr. Siff died and the whole enterprise came to a stop.

Enter Lorimer Moseley - the genius from Australia and one the most incredible thinkers and teachers you can imagine - and his study he published in "Pain" in 2007. He actually did what I was thinking about in 2003.
And it gives me great pleasure to say: of course it worked!

This is what I want you to recognize: don't ever ever ever - not in your job, in life or - as in my case physiotherapy (and photography) - let yourself become stuck in thinking in techniques and applications - start thinking in principles.
That way you are able to adjust what you know according to the circumstances.

The same here: it doesn't matter if you have chronic pain in a limb or in the lower back - feedback is the key. You can't see your lower back - visual feedback is out of the question - so use tactile feedback which works just as well as Herta Flor (another genius) has proven.
If you become stuck in specifics you can't treat LBP because you are thinking that is has to be visual; thinking in principles of "just give feedback" enables you to do so much more.

As for the how to - here are a few pointers:

1) concentrate - by paying attention to what you see and feel you tell the brain that something important is going on

2) 10-15 minutes at a time: you really can't concentrate any longer. Try several sessions a day.

3) Vary the movements - pick up objects, do meaningful stuff

4) take your time - there's no advantage in rushing this

5) one session before bed-time. Sleeping helps with memory consolidation and learning new things (in this case it might "only" be re-learning old things) ;-)

6) and please change your thinking about what medicine is supposed to be and have a close look at what you expect from the medical services - by doing this we'll all be better off in the future.

7) don't let yourself be discouraged to give this type of treatment a try even when "medical professionals" tell you differently. The problems here are that a) most don't know about it and it is easier to say no to a new type of treatment than to take the time to learn about it and b) we medical professionals have shaped our own expectations of what constitutes treatment based on high-tech and other modalities and have often lost sight of what else is possible. We have to realize that it isn't we that heal a person - we are often only there to help a person heal himself - just managing the whole process. The medical field needs to acknowledge this more often I think.

8) at last: try it and share your experiences. Email and comments are always welcome because they provide me with important feedback (see!) ;-) so that I can update my thinking, learn and share it with others to help even more people.

9) be playful. Understand the principle (by reading this series) ;-) and find out how it works best for you.

Here's a short video - kind of a case study so that you can see the effect mirror therapy can have on improving range of motion:

Thanks

2007-11-25T05:40:00.000-08:00

I was invited to do a posting for the monthly pain blog carnival over at howtocopewithpain.org - the topic being thankfulness.
What better way to do this than with this great video:

First of all I want to thank all the scientists who ever lived who allowed themselves to think about things creatively and who didn't care what others thought at the time.

This goes back hundreds of years - among many others to Dr. John Snow who charted the deaths caused by Cholera in London in the 19th century and was able to solve the problem by identifying the causes, to James Lind who found the cure for scurvy - even if no one believed him, to Ignaz Semmelweis who found that washing your hands before childbirth saved lives.

There are hundreds more that should be included in this list - heroes that often nobody has heard of - forgotten by history. But it was they who enabled us to live the way we do - and we should never forget that.

You have to realize that a lot of these people suffered enormously during their lifetime because what they said didn't happen to be the accepted wisdom of the day.
Some went crazy, some killed themselves - but despite that they never stopped telling the truth.

One guy - Werner Forssmann - who later got a Nobel - was fired because he proved (on himself as a guinea pig) that you could put a catheter into your own heart. This technique has saved hundreds of thousands of lives! Imagine people like him keeping quiet about it and watching out for their own welfare - imagine where we would be now - still living in caves waiting for lightning to strike a tree so we could have fire. ;-)

"Big Science" is like Big business - a tough world to live and work in.
And only the courage of creative individuals keeps us going.
My heartfelt thanks to them.

My second round of thanks goes to the Organizers of the TED conferences for putting the amazing talks online.
Never before in my life have I seen so much talent gathered in one place. Every talk is a piece of art. I have no idea about marine biology - but when I watched the talk by Tierney Thys i was deeply moved. I just love watching poeple being passionate about what they do - it reminds me of myself. ;-)

Is there a thing more beautiful than watching someone talk about his or her work - in the process inspiring others?

I don't think so. You just can feel that these people want to do what they do - even if they weren't paid to do so. I wish everyone could experience the satisfaction you can have if you really love your job or your hobby.

Other great - must watch talks are:
- Sir Ken Robinson on education
- Hans Rosling on the developing world
- Dan Gilbert on Happiness
- Robert Fischell on Migraines
- Dean Kamen: watch a genius at work

My thanks also goes to BMW for sponsoring the talks - Bandwidth ain't cheap. ;-)

And now for some special thanks to the person who has influenced my work and my thinking more than anyone else on the planet:
V.S. Ramachandran.

He wrote a book (actually Sandra Blakeslee did - a gifted science writer) - called Phantoms in the Brain - that is still one of the best books about neuroscience out there.

After reading that book in about 2000/2001 I was hooked. The cases he described were just too weird to be true - but as it turned out it's even weirder than we can imagine.

In this talk he gives the example of Capgras Syndrome, Phantom Limb Pain and Synaesthesia.

You can also listen to his 2003 Reith Lectures covering much of the same material.
That's one the things I like about his talk: it's the same stuff he has covered over the past few years - there really is not much new material - but it is also the most succinct version of the issues involved that you can imagine.

Everything you need to know about the neuroscience of the self and pain is contained in that talk. It is the best starting point for your own exploration imaginable.

Starting at 13 minutes into the talk he introduces the biggest breakthrough in treating chronic pain syndromes ever: mirror box therapy.
I especially like the way that he clearly states that it doesn't have to be "high-tech" or expensive to work - but that the treatment is based on solid science. If you are able to exploit the weaknesses of our brain and our senses - go for it any way you like.
I cannot stress enough how important this is!

The medical establishment has - knowingly or unknowingly - created the expectation that big problems require big (and expensive) solutions. An MRI scanner costs millions of dollars and quite a bit of space. It's impressive just to look at - but don't let that fool you into thinking it'll help you one bit.

Yet this exaggerated reliance on for example imaging technology has created expectations that the health care providers are not able to keep up with - costs are going through the roof as more and more people get older and older.
We need to tone treatment down a little - find a new balance between too much and too little.

Mirror Box Therapy has none of the trappings of high tech medicine - yet it is incredibly effective.

And what's even better - it puts treatment back into the hands of the patients!
That's right - you are finally able to treat yourself again.

Structure vs. Function - Part III

2007-11-18T08:47:00.000-08:00

Why this debate should matter to you - the therapist and the patient.

The search for structural faults that are causing pain is still going on.
And it'll continue to do so.
I think it has do do with basic human psychology - we have this need to put labels on everything we see. Our brains want easy explanations - all the time.
Our brains produce visual (and other) illusions because they are hardwired to resolve every computational problem they encounter.

They are not computers running Windows; they can't just crash - they have to continue functioning - even if that means finding patterns in meaningless noise (pareidolia, conspiracy theories, astrology).

So where do you - the patient come in?
Well - your expectations are shaped by this mechanism. You want answers when you consult a health care professional. And those answers better fit your view of the world - or else!

Structural faults like ruptured discs, degenerated vertebrae, pulled muscles are easy to put a finger on - just think of an MRI scan that shows a bulging disc. What's easier then to show you - the patient in pain - that picture and explaining that that bulge causes all your problems. And since an operation could clear that right up you could be pain free again in a week or so.
It's convenient, easy, convincing - and even fits the symptoms sometimes.

Now compare this to a more functional explanation - with or without the scan if you like.
The doctor would explain to you that yes - there is a bulge - but it could be an old one you've had for a year already (without symptoms) - and that the reason you are in pain now is that your brain "has decided" to produce a painful sensation because of some factor that could be biological, social, psychological or all three.

His advice is to keep active, distract yourself as much as possible and adjust your daily life accordingly and check back in one or two weeks if things don't get worse.

Which would you rather pick?
Exactly - option one is simple the better sounding one. Until you had the operation of course and the pain is still there.

That's not to say that all operations are for nothing. But even orthopedic surgeons have started to admit over the past few years that the outcomes weren't that great in cases where the main reason for an operation was pain as a symptom.
Long term studies show that the outcome over the long run is even the same compared to conservative care.
This goes for spinal surgery and other kinds too (think osteoarthritis of the knee).

Pain - like it or not - is in your brain!
It always is - and always will be. It's an emotion like anger, fear, love and all the others. And like all the others it's being put together according to the circumstances you find yourself in.

So if you change the context - you can change the pain - your pain.

Some methods and influencing factors I already have described in my Pain for Dummies Series.

Here are a few more:

- Kinesiotape: How does it work? It's all about low-level cutaneous neural system input - or "grooming" as it's known in primate circles. Have you ever seen chimpanzees grooming each other? That's what kinesiotape does. And if you can honestly say that you wouldn't like to be groomed for a few hours each day you are a liar!

- Feldenkrais: that guy was a genius. Simply brilliant! He recognized that the brain is plastic and likes to learn. That's what happens when you do those exercises - your body learns how to move more efficiently. It's all about feedback and re-programming better motor patterns. When I say Feldenkrais I also mean all the other offshoots his work created: Somatics (faster, shorter - equally cool), Alexander Technique, Rolfing, Yoga, ...
And of course - when you try new movements you have to concentrate a lot - distracting yourself - again.

- Meditation: training how to calm "the mind" - to get the same level of control over your "mental muscles" as over the ones you exercise in the gym.

- Feedback therapies: Mirror Box for CRPS, Phantom Limb Pain and the like. Tactile input for parts of your body you can't see - like our back. And auditory training for tinnitus.

- Redcord: we use this device in our clinic and I have to say it's phenomenal! There simply is no faster way to re-program motor patterns.

- Motor imagery: works. Close your eyes and work out at the same time. Mentally rehearse things that you have to do every day and try to make them more efficient.

- Neuromatrix training: read the blogs - mine, David's and Diane's.

- Educate yourself: the 20th century is over. The expansion of the Internet puts the worlds knowledge at your fingertips (otherwise you wouldn't be reading this!). The more you know about yourself the better off you are.

- Give back: there's nothing like sharing what you have learned or experienced with the rest of the world. By putting your thoughts into words you go over the experiences again - putting them into proper perspective. The only thing you can do wrong is not doing it.

Pain For Dummies - Part X

2007-11-18T07:25:00.000-08:00

or: The End (?)

Over the past few weeks I've tried to explain a few things about pain, you and your brain - and why science is important and how it helps us to understand ourselves.

I will of course continue to post about these topics - but the Pain for Dummies Series comes to an end with this posting.

To sum up the series:

Pain is incredibly complex - it involves the whole brain, it can (and must) be tackled using different approaches (hence biopsychosocial). And we are far from understanding it completely.

Most important however is the fact that there is such a thing as a "brain in pain" - a brain that has learned that there is pain to be expected regardless of what the person does - and that you can re-learn to be pain free!

That doesn't happen overnight of course - you'll need lots of patience - but there is a basic entry level for everyone. Find it and start (re)training - now!

Here's what I covered over the past few weeks:

Part I: What is Pain?, Pain and the Stress Response

Part II: The Multidimensionality of Pain and the Biopsychosocial Model

Part III: The Psychology of Pain

Part IV: Metacognition - the coolest feature you have and didn't know about

Part V: The social aspects of pain

Part VI: Can you handle the truth?

Part VII: What’s this new approach all about?

Part VIII: Practice what you preach!

Part IX: What’s the economy got to do with pain?

I hope that you can use some of the tips and tricks I put into my postings and that they will make your life easier - or better yet point you towards a pain-free future.

Coming up are a few postings about how we can tackle chronic pain from a therapeutic point of view - by exercising the virtual body and giving non-nociceptive feedback for example.

Stay tuned!

Structure vs. Function - Part II

2007-11-11T08:10:00.000-08:00

Let's examine the debate between structuralists and functionalists some more with the ubiquitous ankle sprain for example.

Treatment for such an injury until a few years ago focused mostly on reducing swelling, early weight bearing, .... - and yet the single most important risk factor to suffer from another ankle sprain is still a preceding ankle sprain. The same happens in low back pain (LBP). Your "risk" to suffer from another episode of LBP is greatly enhanced by an episode of LBP in the past.

How come?

Well - the sad truth is that you cannot guarantee joint stability with sheer muscle force - and that was - and unfortunately still is - the theory behind most training regimens. It went something like this: if a joint is injured the best way to provide stability in the future is to exercise the muscles surrounding the joint.

Along come journals like the Journal of Applied Physiology (and others) and show that this simply doesn't work: muscles are way too slow to provide stability.

If you jump on a platform that suddenly tilts under your foot it takes just 10 milliseconds for your ankle to get hurt.

On the other hand muscle takes at least 50 milliseconds to react in the most basic and "primitive" way - with a reflex action.

Let me spell it out for you: muscles contract after (!) the injury has taken place - often making it worse in the process.

Interestingly enough students are taught this in physiology classes - the contraction times I mean. Yet 99.99% fail to make the connection that muscle action isn't sufficient to provide stability.

Lateral thinking rules the day once again. ;-)

You mean to say that training doesn't help at all?

Of course not - but the focus has to be on the timing of the muscle action. Scientists call this the "feed-forward" approach.

Your brain (using the eyes) continually scans your surroundings and the ground in front of you. It then prepares motor patterns based on the visual impression of the surface you are going to step on. In short: your muscles contract way in advance so that they are prepared for the moment when your foot hits the floor. That's when you need the braking force your muscles provide.

It's the same when you try to catch something: your brain computes the path the object travels, factors in gravity (or not - as Alain Berthoz has shown with Space Shuttle Astronauts) - and adjusts your hand muscles so that they are ready to intercept the object. It's all about predicting future events - even when they are just a few milliseconds away.

As for LBP, the same feed-forward mechanism applies: your brain tries to prepare the body for, say - catching (heavy) things by contracting the muscles around your "core". This increases intra-abdominal pressure - thereby enhancing spinal stability and providing a stable "platform" as it where for the extremities. Once you suffer from an episode of LBP this mechanism is put out of action - from then on you use a different motor pattern to control your trunk which isn't up to the demands of everyday life. The deep muscle system of the back stops working and the more superficial muscles take over. They have to exert a lot more force though to keep the trunk rigid during heavy tasks - so they tend to tighten considerably.

On a side note: Rectus Abdominis (the famous "six-pack" muscle) doesn't do anything for increasing intra abdominal pressure. For me it's still the most useless muscle out there.

Only by re-establishing normal motor function - by training coordination and by re-establishing the feed-forward mechanism can you reduce the risk of suffering from another episode of LBP.

Modern rehabilitation has to focus on two things:

one - restoring normal joint play and range of movement (Motion is lotion and creates lots of feedback)

and

two - training the feed-forward mechanism so that the brain becomes better (and a bit faster) at predicting the future, proprioception and reacting faster.

For the first task you are welcome to think in purely structural terms - damaged ligaments, scar tissue formation and so on and so forth.
But for the second one - re-programming motor patterns you have to think like your brain. Sounds strange - I know.

But think about it: your brain has to prepare itself and the body it resides in for a lot of tasks and challenges each and every day. It does so by storing information about previous events (called memories) and building up a huge database about the properties of different objects and surfaces so that it is prepared for the things that lie ahead.

I will come back to this topic with a series about Alain Berthoz book "The Brains Sense of Movement".

How does this picture fit the topic?
Well - some of the same principles are at work here: most people - when the see a fibre optic lamp - just think "lamp".

Me - I see a thousand possibilities. I see movement that can be captured over a period of a few seconds - creating very interesting patterns.

This is what purely structural thinking has lost: it only looks at static structures, snapshots of tissues in different stages (of healing).

Functionalists see change over time, function in a bigger context - and above all a brain that tries to make sense of an outside world and a virtual reality simulation of that world on the inside.

Pain for Dummies – Part IX

2007-11-08T23:08:00.000-08:00

Or: what’s the economy got to do with pain?

Economics is a difficult field to study. Making accurate predictions is hard because human behaviour and decision making are so erratic it’s beyond belief. The emerging field of neuroeconomics is trying to rectify that situation by looking at the brain during decision making processes. Some of the findings are really scary – people prefer short term gain over long term gain for example. Doesn’t bode well for things like working on issues like climate change.

But this blog is about pain – your pain – so how does economics help us deal with it?
I’ve written about the positive effects of work on pain by providing a source of distraction.
But what I want to explore now is one of the basic premises of the science of economics: people react to external factors (without necessarily being aware of them) .
Or: your environment influences your behavior – much more than you know.

Consider my own example: I like to move. I like to exercise. But for the past few years my external environment "didn't let me". There simply was no incentive for me to take care of my own body. I knew that I should've been doing something - but was literally unable to follow my own advice. ;-)
After changing jobs and the place where I live the situation improved dramatically and now "I'm back"!

Even more dramatic are some of the experiments of the 60’s in social psychology:
Zimbardo and Milgram took well adjusted people and put them in difficult situations – Zimbardo used a made up prison environment and Milgram used an authority figure – and look what happened.
Experiments like this show that everyone of us has a range of possible behaviors within him or her – if they are triggered depends on the circumstances we encounter in life.

It’s like the old debate over nature and nurture. Some out there – adherents of the black and white world view still talk about nature vs. nurture. But that’s nonsense: it’s genes and how the environment acts to activate them. If you have a genetic disposition to be afraid of water and you live in the desert those genes are never activated. It’s the combination that determines what happens.

The same with you and your pain: if you are more likely to develop chronic pain due to a genetic disadvantage you have to work on the “nurture” part – that is your environment to reduce the impact. You can’t change your genes – yet – but you can try to lower the chance of those genes being expressed (the fancy way of saying “activated”).
Work on developing helpful coping strategies for example – the pain itself doesn’t necessarily go away – but the impact it has on your life is greatly reduced. Work on distracting yourself – don’t let the pain rule your life.

If you are prone to develop stress related diseases – again: coping, relaxation and distraction are key. But here is where it gets interesting:
“de-stress” your environment – i.e. your surroundings at work and at home.
Peripheral vision works by checking your surroundings for (sudden) movement and drawing your attention towards it; it is one of the systems we have that helps to protect us from dangerous predators – sabre tooth tigers and the like. Since those aren’t around anymore it now reacts to everything that moves – decidedly unhelpful in our modern world.
If your desk or workspace is too open to such intrusions – close it of. Walls are there for a reason!

The same applies to your desk itself: to much clutter is unhelpful – “visual clutter” is enormously distracting. Your brain scans all the items lying around and uses up a lot of energy doing that. That’s why we have bookshelves, cabinets and the like at home – when everything is in it’s place the atmosphere is a lot more relaxed.

Use indirect lighting to create “mood”. Direct light is very harsh – indirect lighting creates softer light which most people find pleasing. Color is another great way to “de-stress” your surroundings. You can choose warm (yellow, red) or cold ones (blue).

One of my favorites is smells: they are very powerful since they are directly channeled into the brain – not having to go through several processing steps like the other senses. It all depends on what you like – but give it a try and find something that’s just right for you.
Same with music – that’s why there are songs for driving, working out, … – the rhythms are able to influence your heart rate.

There are of course things you simply can’t change – but try to find workarounds wherever possible. Know your strengths and build on them – manage your weaknesses.
Use Metacognition to identify which things, objects and situations in your daily life cause problems and work on changing their impact.

Structure vs. Function - Part I

2007-11-08T00:51:00.000-08:00

I guess every field has it's own "vs." debate. They usually last for years without ever coming to a real conclusion.

One would think that by now most people would've noticed that it's not a question of "vs." but of interconnectedness - nature and nurture - not nature vs. nurture.

If you have a gene that makes you more susceptible to developing a certain illness there have to be factors in your environment that activate those genes - otherwise you don't get sick (in that specific way).

The old "vs." debate in Physiotherapy and similar fields is one between structure and function.

There are some who see treating tissues as their main approach - others like me have abandoned those models of thinking (long ago) ;-) and see themselves as "functional therapists" - or neuromodulators - as for example Diane Jacobs does (her excellent blog is here).

Why is there a debate at all?

Well - medicine is still influenced by what scientists/pioneers started when they cut up the first human bodies centuries ago - gross anatomy.

Even today - with all the new techniques that were developed since - medical students start by dissecting bodies and learning about the human animal that way.

What's more - starting with Mixter and Barr in the 30's - every decade more and more and finer and finer structures have been found and are presented as the "pain causing structure". First it was the ruptured disc - now we are down to the vessels that supply the disc and their pressure being elevated causing constricted flow and a sharp rise in pressure. With structural thinking there is just no end in sight - next they are going to focus on molecules being bent out of shape.

And if you haven't realized it by now: those people are dead! Yet medical professionals treat humans that are alive!

You can study the mechanics of flight in this picture - but not flight itself:

Do you see the problem now?

We - as examiners can see muscles and tendons and bones - all clearly discernible - but the Neurosciences haven't found a representation of a single muscle inside the brain yet - they just don't exist from the brains point of view. The brain "thinks" in movements, goals and actions to perform - and uses what's available at the time.

Have you ever seen a runner without legs? With special prosthetics - which are in some ways much better than legs they run just like you and me - yet they have only half (?) of the muscles we think a human being needs to be able to run.

Look at people who had polio - the muscles that weren't affected take over the function of those muscles that are paralyzed.

How does this affect treatment?

Let's look at the example of phantom limb pain: the missing limb hurts, it might be an involuntary clenching or burning pain or whatnot. So the "structural" oriented practitioners started looking for clues in what was left of the extremity. Some of the pain was attributed to the site of the amputation - resulting in another shortening operation, nodules of scar tissue being removed from the stump, the cutting of nerves from the spinal cord to the limb and so on and so forth.

Again the rule of thirds came into play: some got better, some stayed the same, some got worse.

In come the "functionalists" - led by V.S. Ramachandran - building on the work of others of course.

They realized that the cortical map of the amputated limb was still present in the brain - most accessible to study in the somatosensory cortex in the brain. And so called higher centers in the brain act on the information that is contained in those maps - not on what's outside in the real world.

Since pain is produced in the brain Ramachandran speculated that the cause of the pain could lie in the fact that the representation and the visual feedback from the limb didn't match (see Harris Hypothesis for more).

So he gave those amputees visual feedback of an intact limb with a mirror - and the pain vanished quickly.

Those findings have been replicated over and over again - Walter Reed is running a big trial with Iraqi War Veterans to see if mirror treatment is a viable treatment. Traumatic amputations are often much more difficult than "planned" ones.

The sucess rate of this kind of treatment is - at least in small trials well over 90%.

This doesn't mean that the "structuralists" are wrong - but just that they should try to "expand their thinking".

The techniques they use are still useful and are applied by me as well - but the reason why you do something and how you do it is different - helping you in cases when a patient fails to improve.

One kind of therapy that finally started to get around to acknowledging this is the McKenzie method. It originated as a purely mechanical way of treating back pain - but has since then evolved into a method that is able to treat the whole body. The term "derangement" now encompasses all things in a joint that can be "out of whack" - and only cares about if the patient gets better with repeated movement in the preferred direction.
Even large scale trials show that this kind of treatment is very effective. People aren't put into groups based on structural findings - their functional status is all that counts.

I've had discussions with the top people in Germany and the US about openly admitting that they "are only changing neural firing patterns" - not doing anything mechanical with a specific structure - and at least behind closed doors the Germans agreed - the US guru is still not talking to me. ;-)

And this despite the fact that they see how fast people can improve with this method.

Structural thinking is just so easy to grasp and not as "nebulous" as functional thinking - at least to some.

Pain for Dummies – Part VIII

2007-11-04T09:54:00.000-08:00

or: I'll be back!
or: practice what you preach!
or: change in action!

Yes folks - I did what I always said I would: I started working out again.

There was no doubt in my mind whatsoever that I would start doing some form of workout again - I just had to find the right time and the right circumstances. That's what I call the economics of change - but that's the topic of another posting.

And - having paused for quite some time - it feels so good to physically exhaust oneself again.

You guessed right - I didn't take the slow methodical approach - I'm more along the lines of Jeremy Clarkson yelling "Power" when I start and "More Power" when something isn't going according to plan. ;-)

The biggest difficulty in starting an exercise program (or any other training regimen) is always the (felt) lack of time.

And while everyone knows that's not really the problem it is the most frequent reason people give when asked why they don't do regular exercise.

For me - as always - the problem can be tackled from a neuroscientific point of view - that's why the title of the blog is "The Neurotopian"; I envision a future in which every question can be answered from a neuroscientific basis.

So why don't people have time?

Well - it's the same process that's at work when it comes to visual perception - it's called filling-in.

Our eyes have a region called the blind spot - it's where the optical nerve leaves the eyes. There are no receptors there - so we have a big hole in our field of vision. You can test your blind spot and even map the size of it - here.

Curiously enough we don't notice it at all in normal life.

The brain employs a mechanism known as "filling-in" where it "calculates/estimates" what should be in that blind spot and fills in the missing information.

The same goes for touch, for hearing and all the other senses we have. If something is not there the brain doesn't leave a hole but presents us with a complete and whole picture.

Now try this experiment:

take a normal workweek - 24 hours and 7 days and try to remember what you did during that time.

Notice the times you slept, ate, drove to work, ...

Finally - try to remember the times when you did absolutely nothing! Nothing except breathing and staring at the wall waiting for the clock hands to move forward an hour.

I bet you can't find any such time.

Even "doing nothing" involves doing something - even something completely meaningless.

And those are exactly the times you have to identify. There is your ideal workout time!

For me it was coming home on Tuesday evenings at 8pm and just checking emails, looking through Flickr, reading a few blog entries and similar stuff - nothing really groundbreaking. But it became a habit.

Till I realized that none of it was really useful - I could do the same a day later too and have enough time to exercise for a full hour.

Surprise surprise - it worked perfectly. Even better than that - by exercising somehow time afterwards seemed to move more slowly - maybe all those endorphins kicking in - and I still had time to check my email and read a bit.

The problem like I said is not that there is no time - but time that is simply filled with something - anything.

Find it - use it.

Pain for Dummies – Part VII

2007-11-01T10:30:00.000-07:00

Or: what’s this new approach all about?

As described in the previous posting the old paradigm – the body based approach - is still alive and used widely.
The new one is radically different – so much in fact that it seems strange and too simple.
How to explain it so that everyone can understand and benefit from it?

A good starting place are these two great books: Phantoms in the Brain and The Body Has A Mind Of Its Own. They are able to give a much more in-depth view of what it means to have a brain. ;-)

In short: imagine yourself having to drive from say Paris to Berlin. In order to prepare yourself for the journey and to be able to estimate the resources you need (time, food, gas,…) you use a map. The map isn’t the territory – it would have to be on the scale of 1:1 to do that – but it is a representation of the actual landscape you are going to be traveling through.

With the help of this map you can easily measure distances which – combined with speed – give you a rough approximation of how long the journey is going to take. You can check for elevations, roads, highways, restaurants and so on. You are able to plan the journey – including rest stops and a whole lot more solely based on the representation you have lying before you.

Maps are so great in fact that our brains have discovered them millions of years ago. Even better – we not only have one map but hundreds of them – each for one specific function.
Maps of the body are so old that they are hardwired into the genetic structure of our brains – meaning that even when you are born with a missing limb the map for it is still there in your brain.

The modular structure of our brains is laid down very early during development – congenitally blind people (blind from birth) still have a visual cortex and so on.

Maps are so useful because they enable us to react lightning fast; if your brain had to check if there really are two legs when you slip you’d have fallen to the ground before you could react. With a map in place everything is sped up and you are able to recover balance. Most of the time anyway. ;-)

The old paradigm focused on the terrain itself – in CRPS for example treatments were aimed at restoring circulation to the injured limb. What neuroscience has found is that instead the arm being the cause – it’s actually the hand representation (the hand map) that is the cause of the changes we can see.

Other – so called higher centers of the brain – then act on that distorted information; no wonder that the output they produce isn’t the right one – they simply don’t "know" better. The brain is acting on distorted information.

Treatment has to focus on the cause: re-modeling the hand representation as fast as possible.
Fortunately these maps are plastic – that means they have the ability to change. That’s how we are able to learn and acquire new skills – if we learn to ride a bike for example those new motor patterns become hardwired into the structure of our brains. In the case of chronic pain that whole process of learning goes haywire – there is such a thing as too much of a good thing.

Re-training or re-modeling can take different forms – depending on where your individual starting point is: if really all movement with the affected limb is painful then start with motor imagery, i.e. imagining moving the limb. Motor imagery is very effective as a stand alone treatment since it activates the same neural circuits in your brain that you use to do the actual movement. All that’s missing is the motor command that tells you muscles to contract.

After this first step you can start actually doing the movement with a mirror box – the affected side behind the mirror so that your brain is fooled into thinking that the limb it can see is doing what it wants.

You create a congruence of motor intent, motor output and feedback that way.
Gradually the map is remodeled and function returns.

As Harris points out it’s enough for pain to occur when the brain is unable to make sense of divergent information – so pain should subside very quickly when you do the few first sessions – only to return a short while afterwards.
Don’t despair – it just shows that your brain is still able to turn of the pain and willing to learn.

At least this should give you the hope and motivation one so desperately needs when so else has failed.
And the best thing: it’s easy to do.

One can only hope that these new findings spread as fast as possible since even some of the most serious illnesses out there – think anorexia with a 20% death rate – most probably have their origin in these body map disorders.
Reestablishing those maps can alleviate symptoms very quickly and help save thousands of people from suffering.
Spread the word!

Pain for Dummies – Part VI

2007-10-18T00:32:00.000-07:00

Or: can you handle the truth? ;-)

When taking the history of a patient one phrase comes up all too frequently: “I have tried everything”.
To be honest: no – you haven’t.

Here’s why:
We – and this concerns all of mankind – have a huge problem: there is so much information available that we have a hard time keeping up. Add to that that not only would you have to read all this new information – but also understand it and use it – while also working your usual 40 hour+ work weeks.

Change is hard – as explained here. Old patterns – be they motor patterns or other behaviors – are more efficient than new ones. That’s why - especially in times of stress - we use them over the new ones.

The treatments you as a health care professional provide are on the safe side – something you have established over the years. You think you know that they work and you apply them over and over again.
Problem is that they are mostly based on what I call the old paradigm – the purely body based approach (structural thinking).

You have to remember that the brain was out of reach of serious scientific study until 10-15 years ago. People in pain could describe their problem – you could look for clues what’s wrong with their body – but there was no way to have a look at their brain in pain. That’s why treatments for tinnitus, phantom limb pain, fibromyalgia, CRPS and other similar ailments focused on the changes that were visible to the naked eye so to speak.

That’s why – when you look at the studies done using those kinds of treatments you always end up with the “rule of thirds” as I call it – a third of the patients got better, another third stayed the same and the rest got worse.
It's like using a shotgun: some pellets hit the bad guy - the rest misses or injures an innocent bystander. In medicine you prefer the magic bullet that is able to hit the problem directly - nothing more - nothing less.

It’s no ones fault really: there simply was nothing better at the time.

This however has changed rapidly during the “Decade of the Brain” – now we have treatments that are able to address the cause of the problem. And here we encounter the second obstacle on our way forward: health care professionals have applied those old treatments for years – with moderate success (think shotgun). But since those illnesses were so hard to treat even 30% improvement seem like a good deal. Those old treatments are “hardware” based – flashing lights, infusions, pills, … - they all seem very thought out.

They are – there really is no other way of describing it – “sexy”. They are what you – the average Joe – came to expect from medical professionals (in a future posting I'll write at length about the link between expectancies and experience).

Along come the neurosciences and take away all the fun by having you use a mirror.
And even I have to admit: it just sounds too simple. Moving both hands while looking into a mirror? – you dare call that a treatment? Are you nuts?
Even worse – you – the health care professional – doesn’t have to do anything but explain what to do?
Remind me why I should pay you for just talking to me?
The next guy is even worse – telling me not to move anything but just think about it!
Has everybody gone crazy?

Now imagine having to explain this type of treatment to others in your field – can you imagine how a hands-on trained physiotherapist is going to react?
Asking someone to change their whole approach of thinking about a medical problem and changing his treatment methods accordingly isn't a step taken lightly.

And then there is the word “psychological”.
I treated a MD once who himself suffered from phantom limb pain. When I asked him about mirror training he said that he read an article about it once but never tried it because it was published in a Psychology journal.
If you can’t convince people like these – imagine how long it’ll take till a new generation of health care professionals is in the majority and the “new” treatments become universally accepted.

As for you – the patient: what can we learn from this.
a) Again: no - you haven’t tried everything because the people treating you aren’t aware of every option available.
b) the Internet comes to the rescue: information is free – you can read the articles yourself; the better educated you are about your problem the better you can help yourself
c) forget “the media” – they have the “empty space” problem, i.e. they have to fill 24 hours of programming and the pages of their magazines and are very unreliable sources of information. They are clutching at straws –producing huge amounts of "Fark" - hyping everything; pain is serious business – it doesn’t need the latest trend – but good science.

Pain For Dummies - Part V

2007-10-07T02:14:00.000-07:00

The social aspects of pain.

Humans are social animals through and through. Our brains are hardwired to enable us to live in groups of up to 150 people - what others sometimes call a tribe.
Nowadays with over 6 billion people around we have to be more open and willing to meet and interact with others - but our peer groups (those that are close to us) - remain relatively small.

How do children learn to speak a language? How do they learn how to eat with tools? Where do they get their behavioral norms from?
At first from their parents - since they are there 24/7. They observe behavior, speech patterns, motor patterns and simply try to do the same.
As they grow older other people come into their lives - and they adapt to those as well. As social animals we want to be able to fit in and communicate with others - so we have to find a way to connect with them.

That's why babies and children have no problems learning several different languages at once - the need to connect and their ability to learn is nearly limitless.

What about pain?
First we have to distinguish between the subjective experience of pain which isn't visible and the outward expression of someone in pain. It has been suggested that the basic pain threshold is pretty much the same in every person (apart from "redheads" who are more sensitive).

The most striking difference however occurs in how people of different cultures express their pain - how they show the world around them that they are in pain. Remember - this is also a learned response! But if you are from a different culture that has it's emphasis on let's call it "quiet suffering" - you might be overwhelmed when someone shows up who is very agitated although he has only a minor injury.

That's why it's so essential to have some kind of objective measurement. I had a patient once who - despite rapid improvement in function - still complained about the pain in the most exaggerated fashion. Even tests that are meant to provoke the pain were negative - but asking him about how he felt got me the same response every time. Since in his case there was only acute trauma and pain I felt very confident that his description was something cultural and no longer something physical.

We should also be aware that the behavior we see in people is sometimes a reflection of what the medical community has "done" to them. Imagine someone in chronic pain who keeps on going - someone with a positive and life-affirming attitude.
Now put that person through a medical journey from hell - no one takes him seriously, no one listens time to listen and so on and so forth.
One simple response to such treatment is to start to exaggerate the outwardly visible part of the pain experience!

If people don't pay attention - you have to do something to change that; small children are masters at this - they use their acting skills to the fullest and without holding back.
Just watch them when they feel they don't get the attention they deserve - suddenly they start limping, develop "stomach pain", .... - they learn that by faking symptoms they can get what they want!

I'm not saying that these responses are intentional - they are learned and become automated - like the rest of our behaviors. In principle they work like a simple reflex - if you get the desired outcome the behavior is reinforced.

But as we have seen before we have this thing called metacognition and can become aware of these behaviors and change them.

The lesson for therapists is this: if you see exaggerated illness behavior (that's the technical term) - listen, educate and be a honest health care practitioner. These people don't need another snake oil salesman.

Is there a message for patients as well?
To be honest - I don't know yet. As soon as I come up with something for you to work with I'll let you know.

Hollywood also uses exaggeration as a tool: ;-)

Pain For Dummies - Part IV

2007-10-03T05:46:00.000-07:00

Metacognition - the coolest feature you have and didn't know about.

Let's face it - changing one's habits isn't easy.
Just watch smokers who unsuccessfully try to give it up.
Our brains are prediction machines - they use experience and other stored information (motor patterns) to get us through the day.
That's why we are able to identify people by the sound alone that they make when they walk - because they always walk that way (the same motor pattern is used over and over again).

Using established motor patterns and habits makes sense because it doesn't require any attention and is therefore a very efficient process - as long as things go according to plan.

It is also very quick - so that you are able to regain your balance very quickly after you slip. If you had to do something like that consciously you would start sending signals to your muscles only after you were already lying on the floor. It's incredible to see just how slow our brains get when the cognitive demand is even just upped a little: see these kind of tests/games for example.

The message is this: learning/re-learning requires time and a non-threatening/not-distracting environment. If you want to learn something new your brain has to be convinced not to use the fast and efficient old pattern - but the slow, inefficient new one.

Try this simple little experiment at home: brush your teeth with your other hand tonight. Sounds simple enough - right?
After you've done this think about people who have to learn to walk again after a stroke and maybe you'll be able to understand what they have to achieve.
I'd rather climb Mt. Everest than ever having to do that!

This far we have only talked about motor patterns - but what about habits?
Well - it's all just electric signals - so we can treat them the same - the brain does so too.

Thoughts - those that are automatic - are the same as motor patterns. They just aren't visible to an outsider. They are also stereotypical - based on experiences and memories. If you express them outwardly they are mostly called "prejudice".

Think about it: our brains form categories for everything around us - they have to in order to be fast enough. When you look at a picture like this your brain doesn't really "look" at it but simply calls up the appropriate categories (toys, Playmobil, bath, ...) and constructs the visual experience you have.
And it has no problem making huge mistakes doing this. That's why 99% of people fail to notice that the Playmobil figure has a frowny face!

And that's why we are prejudiced: experiences we have with only one person with a "special" characteristic are applied to the whole category that person belongs to!
"All Men are the same" is just one of those things we say and hear all the time.
But the same goes for skin colors, professions, weight, height - every observable difference to oneself really.

Where does chronic pain fit into all this?
Pain is in your brain - it has to be. And we know from research that people who suffer from chronic pain react automatically with a stress response when they just read words that are associated with pain! This alone can lead to an increase in their pain!
Do they know this - are they aware of it? No.
It's an automated learned response that is outside of conscious awareness.

But - and this is where the cool feature of Metacognition comes in - you can learn to become aware of this automatic reaction if you choose too.

Metacognition means "thinking about thinking" and is the same as watching yourself walk in front of a mirror. You observe an automated motor pattern/habit - thereby creating feedback that you can use to change the pattern.

Let's say you don't like dogs - your automatic thought is something like "He is jumping up and down because he is going to bite me in the leg."
Changing this reaction requires you to become aware of it - just "stand back" and watch what your brain and your body does when you see a dog. Heart rate? Pulse? Breathing? Muscle tension?, ... - just observe these reactions.

That's the first step you have to master: you have to notice all those little things - especially the rise in muscle tension in stressful situations. You have to become aware of the position of your shoulders in order to be able to change it later on.

And just to give you a rough idea of how long this first step takes: it'll be well into 2008 - still 3 months away at this point - before you are any good at it. Think weeks and months instead of days. That's why "old habits die hard".

The good point is that even a little experience is better than nothing and you can start improving the situation right away.

The second step is to actively stop the automated reaction. As soon as you start thinking "He is going to bite me!" - interfere.
Rationally observe the situation, look at the real facts - not the ones your brain is pumping out - and act on it. The best way to do this is to find someone who has a dog and explains their body language to you. Interact with one (a friendly one of course) and simply get to know them.
I did this myself a few years ago and am no longer afraid of them because I can tell from the way they move that they are mostly just curious about who you are and want some attention.

Again - when it comes to chronic pain - stop those automatic reactions.
Since the stress response is the easiest to feel and observe it's a good starting point - that's why relaxation techniques often bring fast relief. Like taking a bath:

The other things like thinking "This is going to hurt" when you perform a movement are a little harder to change - but it's not impossible.
Take your time doing them, don't do too much at once (pacing) and gradually expose yourself more and more in order to adapt. Sleep on it in order to establish new patterns.

By the way: in Psychology this form of therapy is called Cognitive behavioral therapy - and it is extremely effective.

Pain For Dummies - Part III

2007-10-03T04:27:00.000-07:00

The Psychology of Pain.

This is a big one - probably the most important factor contributing to the development and treatment of chronic pain.

First let me get one thing out of the way: there is a link between chronic pain and psychological problems (depression, ...) - which means that yes - pain is (only) in your mind/brain.
But - and this is good news: we still can't tell for sure which comes first!

Imagine yourself having to live with chronic pain day in and day out. Going from doctor to doctor - spending a lot of time and money on treatments that don't work - loosing friends, social support, .... - who wouldn't get depressed? It's damn near impossible to stay happy when you hear the stories of people who went through hell for years on end. It's normal to become depressed when there simply is no end in sight to the suffering you have to endure.

What it comes down to is this: there are people who are just better at coping with difficult situations than others - copers vs. non-copers. Some people are just able to handle everything that life throws at them - no matter how horrible we think it is what they have to go through. Think imprisonment (concentration camps), torture, war, accidents where you have to cut of your own arm in order to survive.

Impossible? Definitely not - there are tens of thousands - hundreds of thousands (?) of people who are able to cope with such things. What happens is that just as we have a healing response when it comes to our tissue we also can heal psychologically. Our psyche receives "damage" and goes through the same stages that healing tissue does.

The basis for who is a coper or a non-coper are probably the same as for everything else: it's partly genetic - so choose your grandparents wisely ;-) - and the environment either activates those genes or it doesn't.
Nature and nurture instead of nature vs. nurture.

Let's say you are one of those who was unfortunate enough to have the wrong genetic code and is more likely to be a non-coper/pessimist.
What can you do to improve your situation?

- Distract yourself: attention is a limited resource; if you concentrate on the pain it gets worse - shutting out everything else. Focus your attention on something else and pain is reduced.

- Find an outlet: put a rat in a cage and give it random electric shocks; the rat has a chronic stress response leading to high blood pressure, osteoporosis and ulcers. Give the rat an outlet - something it can bite for example - and nothing happens. If you put a weaker rat in an adjacent cage the rat that gets the shocks runs over and bites the other rat that is just sitting there. Guess who gets the ulcers now?
I think everybody knows these two types of people: the ones who have to jog for miles every day and the others who take out their frustration on their subordinates. I recommend the first way of coping!
And while you are at it buy this book. Trust me. It doesn't get any better than this.

- Write about it. Pennebaker has done some amazing work on this. Expressing emotions helps enormously in dealing with them. I think that this has to do with the way our brains are built - we have two hemispheres that are organized differently. One hemisphere is the "human" part - emotional, creative, ... - the other is the more "robot" like part: pure rationality. There is a bridge between the hemispheres - the corpus callosum - but it can't transmit every bit of information - it's bandwith is limited.
If you use your eyes however - by reading something you just wrote down - the part of the brain that didn't have anything to do with the creation of those words and thoughts gains access to them through a different channel and is able to contribute too.
That's why it's also helpful to take out pen and paper and start drawing sketches when you are stuck working on a concept or a presentation.
Mind Maps also work by using this pathway; as soon as you are able to use all of your brain - and the differing points of view the hemispheres have to offer - the sky is the limit. ;-)

- Do something different. I can't stress this enough: keep learning - forever. Novelty is one of the best ways to distract yourself because learning a new skill - be it a new sport, a new language, a new way to move your body needs a lot of resources. It is estimated that we can only keep our focus for a maximum time of 15 minutes - after that our brains start to get tired.
Compare your sleep quality after a normal day with the quality you have when you solved a new type of puzzle before going to bed.
Our brains use the time we are asleep to consolidate memories and to add to the "experience database". If you give your brain something to do during the night it'll do so happily - leading to deeper and more refreshing sleep.
Yes - you can distract yourself even when you are unconscious!
Problems that seemed unsolvable the day before are often gone the next day; I had that experience a few years ago playing Panzer General: I just couldn't get past the Russian Defences at the battle of Kursk. After dreaming about it (!) I woke up and was easily able to smash a hole into their front line after which my tanks were able to pour through.
Imagine that: achieving victory through sleeping well - not by working harder. ;-)

If you want even more advice on how to become a better coper familiarize yourself with this very exiting branch of psychology: Positive Psychology - initiated mainly by Martin Seligman.

For those to take the test - don't despair - pessimists (like myself) are more prone to depression but at least we are able to see the world "as it really is" - and not through pink-colored glasses. That has it's advantages too.

Pain For Dummies - Part II

2007-09-23T06:45:00.000-07:00

The Multidimensionality of Pain and the Biopsychosocial Model.

With the arrival of brain scanning techniques like fMRI and PET-Scans the Neurosciences really took off. Until a few years ago the brain was still just a black box doing mysterious things and the only clues we got as to it's inner workings was done by observing the output it produced.

That's why there are still some who think that there are pain fibres in the body or specific pain centers in the brain. Anatomy and all the other sciences had nothing else to work with and postulated their findings as the "only truth".

Today we know that pain is a multidimensional problem - it has biological causes and consequences, psychological components and acts itself out in a complex social environment.
It's not longer sufficient to draw a picture of a boy burning his foot and following a line to his brain that represents the pathway the pain travels to be a successful therapist.

In order to be able to treat pain - especially chronic pain conditions - you have to be aware of all the components of the pain experience. The best approach to date to describe this complex interplay of different fields and specialties is the so-called "Biopsychsocial Model" (of Health and Illness).

It postulates that in a lot of situations the pain itself isn't the biggest problem - but the way the person in pain or those around him/her perceive and deal with the pain. This goes all the way from family members who offer too much help to doctors and therapists who don't take the patient seriously and even society as a whole when it comes to things like sick leave and sick pay.

Let's look at some of the parts that make up the pain experience:
The biology is very complex - from nerves to neurotransmitters and even specific genes that make some people more likely to experience (chronic) pain.

These are the stages an acute trauma goes through:
Tissue is damaged - leading to local inflammation to initiate the healing response; the immune system is activated to combat infection, a general and short term stress response is activated to enable us to get away from the pain quickly and to prevent further damage.

In this case - acute pain - nociceptive signals are sent to the spinal cord that modifies these signals according to their importance and sends them up to the brain for further processing. At the spinal cord level reflexes kick in - stereotypical motor patterns to protect the limb or the body.

The brain - based on experience and the circumstances the trauma occurs in decides whether or not to "label" the incoming signals as "pain producing signals". If for instance you are in a serious car accident there are more important things than the abrasions or contusions you have - the brain is more concerned with your survival - hence people after serious injuries don't feel any pain - what we call "shock". The nociceptive signals are all there all right - as are the other responses your body initiated to repair the damage - but no pain - at least initially.

If all goes well the damage is eventually repaired, the stress response is shut of very quickly since it is only useful during the traumatic event itself, nociception stops and the pain goes away.

This short outline is already able to give us a lot of clues as to what and where things can go wrong after we have hurt ourselves. The most important thing however is that the biological part is only one piece of the pain experience. As we have seen it's not enough to have nociception - you need a brain to process that information; and if that brain decides to ignore the peripheral input it can do so. It can also decide to produce pain without nociception.

This is where the biopsychosocial model comes in - it recognizes that pain really is an experience that has different factors that contribute to it.

I think most people can relate to the fact that pain is especially painful after we have done something really really stupid - it hurts more because we are ashamed:

Pain For Dummies - Part I

2007-09-23T03:31:00.000-07:00

or: what you always wanted to know about pain but were afraid to ask.

What's this pain thing all about then?

Well - acute pain has a lot of useful functions: it is a warning signal that draws our attention towards a damaged area (or to the potential of damage occurring in the future). It enables our brain to react even before we become aware of it. It protects us from doing more damage, and signals - by way of muscular action - other people that we have a problem in a specific part of our bodies (just think of the way you hold your arm when it hurts).

It also interferes with cognitive processes by altering Emotions and Mood - which is another way that other people can tell that there is something "wrong" with us. What good is pain if you can't communicate it to the world around you?

Some used to think that there is a pain center in the brain. But all the brain imaging studies done over the past 10 or more years show a different picture: pain processing centers are everywhere. Pain is a so-called multidimensional sensation - it's the unique combination of effects it has that makes it so powerful.
It invades every aspect of life - and vanishes just as quickly when the danger is gone.

The most dramatic way to show how important pain is in everyday life is in people who are born without the ability to feel pain (congenital insensitivity to pain); it is a very rare disorder - but with very dramatic effects. If one of their bones is broken they still use it as if it were alright - leading to more and more damage and life threatening infections.

The best definition so far is the one provided by the IASP:
"An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

Notice the "described in terms of such damage" - that's my favorite part. Think about a visit to the dentists office; for a lot of people there doesn't have to be pain in order to feel it. The smell, the sounds, the faces of others in the waiting area and the (bad) memories one has about previous visits is enough to elicit a stress response - and lead to "imaginary" pain.

There are two important lessons here:
1) our brains are pattern seeking and prediction making machines
and
2) the link between stress and pain

1) our brains start looking for patterns the moment we are born. Babies will smile at anything that resembles a face - even a piece of cardboard with two eyes and a mouth. Our brains are hardwired to look for faces especially - that's why we are able to see them anywhere - in clouds, in trees, ...
That's why highkey portraits work so well - they reduce a (human) face to the most basic structures our brains seek - eyes, a mouth and a bit of skull outlined.

So if you brought your brain with you to the dentist it starts analyzing the situation: the smell of antiseptic, the high-pitched sounds of the drill, the facemask (very uncool and unintentionally threatening) - and perhaps bad memories from past visits.

How can your brain not see a pattern that says: "Beware - Pain ahead!". It has to do this - it's hardwired to protect you.
The same goes for every other painful experience you ever had - if your brain recognizes a similar pattern it will make you uncomfortable in advance of the actual experience. It prepares you for action.

2) The "stress response". How does your brain prepare you for such a situation when you are - based on the brains prediction - likely to experience pain?:
by up-regulating your natural stress response - changing the heart rate, shutting down digestion, pumping adrenaline into the bloodstream, ... - all the reactions your body needs in order to flee and or to survive.

You have to remember that our brains developed over several hundred million years - so they still expect sabre-tooth tigers to jump at us from behind mailboxes - not dentists who want to help you. Our brains have learned that overreacting is better than the other way round and essential for survival.

So today any stressful situation leads to the full array of stress responses.
And this is the simple link between stress and pain. Stress makes you more likely to experience pain - and as such relaxation techniques are helpful - they remove part of the pain experience which can make pain easier to live with.
Actually short term stress reduces pain (think the "shock" after a traumatic event) - but long term stress heightens it.

In the next posting we will look at the multidimensional nature of pain.

Work Issues and Pain

2007-09-02T08:56:00.000-07:00

Work Issues and Pain. "How does pain affect your work life? Are you able to work? Has pain forced you to give up work?"

I was invited to address a topic related to these questions, along with several other people who blog about pain, by How To Cope With Pain. See my post here. To see all the other posts in this carnival, go to the How To Cope With Pain blog.

Stop and think about work for a moment.
Not about your work - but about what work means, what it is and what it could be like.
If you look at some of the more common family names in Germany for example you'll find a lot of people that have a profession as their family name - "Müller" (Miller), "Zimmermann" (Carpenter), "Schuster" (Shoemaker), "Metzger" (Butcher), ...
That means that at one time people where defined by what they did for a living.

How about you?
Does your work give you your identity - or at least part of it?
If it doesn't - what does that say about your whole life situation?
I think that it is absolutely impossible for someone just to have a job. Work does so much more: it structures the day, gives you an income, provides you with social support, takes your mind of things, ...

Not all jobs are created equal though. Some even add to the problem - or are the cause of all the trouble you experience. If that is the case it's time to leave - fast. The stress response we all have is a wonderful thing - it helps us get out of trouble by preparing our body to fight or to get away quickly.

However - if the stress response is turned on constantly our bodies start to suffer very badly. Tissue breaks down and isn't rebuilt properly, oxygenation is surpressed in certain areas, digestion is shut down, bones become brittle - all leading to severe stress related diseases that crop up later in life in a lot of people.

If you can't get out - you have to find something that takes your mind of things in your free time. Yes - you have to - otherwise things will turn out bad. Being under chronic stress makes you more vulnerable to develop chronic pain problems. And if you already suffer from chronic pain the additional stress of the workplace doesn't help either.

In an ideal world - or "fantasy world" as some would call it work is a big help. Apart from the financial aspect distraction is the factor that is most important. Our brains have only a very limited working memory. That means we can only focus on one thing at a time. If you have a chronic painful condition your attention is automatically drawn towards the painful experience. If you have a demanding task at hand however your brain can't deal with these two things at once - it has to shut out one of them.
Ideally the painful one of course.

Regardless of what you are doing for a living - try to do everything - even movements that you have done for years - with a fresh "mind" - starting from scratch. Analyze the movement, pay attention to it. That way you "overload" your brain with fresh visual and sensory information - hopefully distracting yourself and your brain away from the pain.

Do this long enough and some (all) of the painful movements you experienced before might be re-wired (or overwritten) - in a non-painful way.

If you had to stop working because of the injury or the pain - find something that gives you some of the same positive things work provides: a sense of purpose, structure, motivation, a creative outlet - anything but doing nothing! Like I said - Distraction is the key.

Happy Labor Day!

It's a tough job but somebody has to do it: ;-)

"Filling-in"

2007-09-02T05:38:00.000-07:00

"Filling-in" - könnte man mit "Ergänzung" ins Deutsche übersetzen - ist ein sehr interessantes Phänomen. Man beschreibt damit den Effekt der Komplettierung/Ergänzung/Auffüllung von "leeren" Stellen die - laut unserem Gehirn - nicht leer sein dürfen oder es aller Wahrscheinlichkeit nach nicht sind.

Beispiel: wenn wir vor einer Hecke stehen und sich dahinter ein Objekt befindet dann ergänzt unser Gehirn automatisch die Teile die wir nicht sehen können. Wir nehmen das Objekt als Ganzes war - nicht nur die kleinen Puzzleteile die wir tatsächlich sehen können.
Aus Erfahrung (und Wahrscheinlichkeit) heraus ergänzt unser Gehirn die fehlende Information.
Ein harmloser und hilfreicher Prozess.
Auf diese Art und Weise nehmen wir immer eine komplette zusammenhängende Umwelt war.

Die Stelle an der unser Sehnerv das Auge verlässt empfängt keine visuellen Informationen - wir sind an diesem Punkt blind. Das Gehirn nutzt die Informationen angrenzender Bereiche um diesen Punkt so aufzufüllen dass ein einheitliches Bild entsteht.
Man kann diesen Effekt hier sehr schön testen und gleichzeitig seine Grösse ausmessen (linkes Auge schliessen und mit dem rechten das Kreuz fixieren, Kopf vor und zurück bewegen bis der Punkt auf der rechten Seite verschwindet).

Wie all diese Phänomene ist "Filling-in" nicht nur auf das Auge beschränkt - wir hören auch Töne die es nicht gibt - verschiedene Beispiele hier.

Auch der Bereich der taktilen Wahrnehmung ist betroffen: die "Cutaneous Rabbit Illusion" ist hier das beste Beispiel; es handelt sich um eine klassische Illusion bei der man 2 voneinander entfernte Hautstellen schnell hintereinander stimuliert - z.b. das Handgelenk und dann den Ellenbogen - und es sich für die Probanden so anfühlt als ob auch der Unterarm dazwischen in bestimmten Abständen berührt worden wäre - als ob ein Hase den Arm hinaufhüpft.

Diese Illusion wird direkt vom Gehirn selbst erzeugt: der Somatosensorische Cortex - der unter anderem für die Verarbeitung von taktilen Reizen zuständig ist - wird in den Bereichen aktiv in denen die Illusion gefühlt wird.
Ich bin nach wie vor überzeugt dass man diese Illusion theraputisch nutzen kann wie ich hier vor längerer Zeit spekuliert habe.

Wenn ein Körperteil bei chronischen Schmerzpatienten so empfindlich ist, dass man ihn nicht mehr anfassen kann weil sofort Schmerz ausgelöst wird, könnte man an den Stellen, die direkt daneben liegen Reize setzen, die dann "durch" den Schmerzbereich laufen.
So müsste man den krankhaft veränderten Teil der Gehirnrinde erreichen können ohne mehr Schmerz auszulösen. Wäre wahrscheinlich schon mit einem TENS Gerät machbar.

Bewegung und Erfahrung

2007-09-02T01:42:00.000-07:00

Mein Bruder hat in einem Kommentar folgenden Textauszug gepostet:

"It's amazing, even with 16 pixels, how much our subjects have been able to do," says Professor Mark Humayun who has developed the device at the Doheny Eye Institute at the University of Southern California in San Francisco. "We were completely wrong... We thought from simulations that 16 would give you distinction only between light and dark and maybe some greyscale." In fact patients are able to tell the difference between objects such as a cup, a plate and a knife. They can also tell in which direction objects are moving in front of them. "The brain is able to fill in a lot of the information," he adds. (Spotlight, August 2007, "A second chance for sight", S. 28ff)

Man kann hier sehr eindrucksvoll sehen wie wenig Information unser Auge liefern muss damit wir uns in unserer Umgebung zurechtfinden können. Der Rest wird nach Bedarf von unserem Gehirn ergänzt ("Filling-in"); Erfahrung spielt hier die grösste Rolle.

Der Bereich unseres Auges mit dem wir scharf sehen können - die Fovea ist winzig. Um das auszugleichen und uns trotzdem einen guten Überblick über unsere Umwelt zu verschaffen nutzt unser Gehirn einen anderen Mechanismus: aufgrund von als wichtig eingestuften Informationen (v.a. Bewegung, laute Geräusche) wird ein Orientierungsreflex aktiviert der die Augen (und evtl. den ganzen Körper) in die Richtung des relevanten Stimulus lenkt.

Das sieht man sehr schön wenn ein Auto mit Sirene vorbeifährt - die meisten Menschen schauen in die Richtung des Geräusches und drehen sich oft sogar um.
Daraus lassen sich für den Alltag gleich ein paar Lektionen ableiten:

- es wird nicht nur der Körper auf den Reiz (Bewegung, Geräusch) ausgerichtet - sondern auch die Aufmerksamkeit umgelenkt. Die Produktivität sinkt also deutlich wenn man an einem Schreibtisch arbeitet an dem immer wieder jemand vorbeigeht. Jede Bewegung die man nur aus dem Augenwinkel heraus wahrnimmt lenkt ungemein ab. Das ist auch zu beachten wenn man z.b. Spiegeltherapie zuhause durchführt - möglichst in ruhiger Umgebung arbeiten.

- Damit man schnell genug reagieren kann ist die Bewegung der Augen mit der Aktivität der Nackenmuskulatur gekoppelt, d.h. die Augen bestimmen zu einem Grossteil was die Nackenmuskeln machen. Wer also Verspannungen im Bereich des Hinterkopfes hat sollte beim Training/zur Entspannung dies berücksichtigen und Augenbewegungen ins Training mit einbeziehen. "Augengymnastik" eignet sich natürlich auch für zwischendurch um die Verspannungen gleich gar nicht entstehen zu lassen.

Auf dieser Seite findet sich ein sehr interessantes Experiment:
anhand von nur 15 Punkten die sich bewegen und an den Gelenken angebracht sind können wir verschiedenste Qualitäten unterscheiden - ist es ein Mann oder eine Frau? schwer, leicht?, traurig, fröhlich? nervös, entspannt?
Unser Gehirn interessiert sich in diesem Fall nicht für die Punkte an sich - sondern für das Verhältnis der Punkte zueinander.

Auch diesen Effekt kann man im Alltag ausnutzen:
will man als Radfahrer oder Jogger besser gesehen werden ist es am besten die Leuchtmarkierungen (die man haben sollte) in Gelenknähe anzubringen.

Interview

2007-08-15T05:02:00.000-07:00

Mein erstes Interview ist jetzt online! - ich hoffe dass noch einige mehr folgen werden. ;-)
Danke dem World-Wide-Web kann man sowas praktisch per Email durchführen - wäre auch wegen den verschiedenen Zeitzonen etwas schwierig es live zu machen.
Die Fragen hat gestellt:

Sarah M. Whitman, M.D.
Clinical Assistant Professor
Department of Psychiatry
Drexel University College of Medicine

Und die Antworten sind natürlich von mir:

Ich bin immer wieder auf's Neue überrascht und begeistert wie einfach es ist mit bestehenden Technologien solche Kooperationen ins Leben zu rufen.

Viva La Revolution! - Teil 5

2007-08-15T02:41:00.000-07:00

Wie schon mehrfach beschrieben greift unser Gehirn - aus Zeit- und Resourcengründen - auf Karten auf der Gehirnrinde zu die die Körperoberfläche abbildet.

Wir wissen auch dass diese Karten sich ständig verändern/anpassen.

Wesentlich schockierender ist es dass wir sogar Teile unserer Umgebung als zu unserem Körper gehörend empfinden können!

Man nehme dazu eine Versuchsperson, einen Tisch und eine Gummihand (Faschingsbedarf) ;-).
Die Person setzt sich an einen Tisch und legt die Hände auf die Oberschenkel. Der Tester berührt nun gleichzeitig die Gummihand die auf dem Tisch liegt und die echte Hand unter dem Tisch.

Da nun im Gehirn des Probanden die visuelle Information von der Gummihand mit der taktilen Information der echten Hand zusammentrifft "glaubt" der autonome Teil des Gehirns dass die Gummihand die echte Hand ist - schliesslich "sieht" es ja dass die Berührung und die visuelle Kontrolle zusammenpassen.

Macht man das einige Minuten wird es sogar als schmerzhaft empfunden wenn der Tester plötzlich mit der Faust auf die Gummihand schlägt.

Und nur dass niemand glaubt dass das nur bei bestimmten Personen funktioniert: diese und ähnliche "Tricks" funktionieren bei jedem Menschen der ein Gehirn hat. Unsere Gehirne sind einfach so geschaltet dass sich solche Lücken ausnutzen lassen. Wir können einfach nichts anders - auch wenn wir wissen dass alles nur eine Illusion ist.

Soviel zu allen Diskussionen die die Wörter "Schmerz" und "Psyche" enthalten.

Es geht aber auch noch viel schlimmer - eine Gummihand sieht wenigstens noch aus wie ein Körperteil der zu uns gehören könnte - aber das gleiche Prinzip funktioniert auch mit der reinen Tischoberfläche. Auch die Verwendung eines Blindenstocks führt zu dauerhaften Veränderungen des Körperbildes wie man erst vor kurzem gezeigt hat: Abstract.

Werkzeuge sind deswegen so wichtig für uns Menschen weil sie im wahrsten Sinne des Wortes eine Verlängerung für unseren Körper darstellen. Und nur deswegen sind wir auch so geschickt im Umgang mit ihnen.

Unser "peripersonal space" ist wie ein unsichtbares "Kraftfeld" um unseren Körper herum den unser Gehirn als zu uns gehörend behandelt. Sonst könnten wir ja auch durch keine Tür mehr gehen wenn wir einen grossen Rucksack auf dem Rücken haben oder wir würden ständig mit unseren Kleidungsstücken irgendwo hängenbleiben.

Bei normalen Menschen ist dieser peripersonal space ungefähr so breit wie wenn man den Arm ausgestreckt hält - die gleiche Distanz also die man anderen Menschen gegenüber einnimmt wenn man mit ihnen redet.

Benutzt man Werkzeuge regelmässig, dann werden sie nach und nach ins Körperschema mit aufgenommen und man empfindet Berührungen am Werkzeug so als ob der Körper direkt berührt worden wäre.

Man vermutet dass inzwischen dass Krankheiten wie Anorexie und andere "Body Image Disorders" auf einem verzerrten/veränderten Körperschema beruhen. Diese Menschen empfinden ihren Körper anders (weil sie die Information von der Karte auf der Gehirnrinde abrufen) als er in Wirklichkeit ist. Nur eine Veränderung des Körperschemas kann hier in der Therapie effektiv sein.

Viva La Revolution! - Teil 4

2007-08-12T10:09:00.000-07:00

Der autonome Teil unseres Gehirns ist sehr alt - ein Überbleibsel aus grauer Vorzeit. Deswegen hört man auch immer wieder die Begriffe eines reptilischen Gehirns, etc.

Um das Überleben zu sichern ist es wichtig sehr schnell reagieren zu können - was sich in den zahlreichen Reflexen zeigt die wir alle "in" uns haben. Reflexe sind automatische Reaktionen die uns ohne Überlegung aus einer Gefahrensituation befreien sollen. Wir haben keine bewusste Kontrolle darüber.

Diese Aufteilung geht sogar soweit dass unser visuelles System in zwei getrennte "Pathways" aufgeteilt ist - den "where" und "what" pathway.

Der "where-pathway" hat nur eine Aufgabe: unserem Gehirn möglichst schnell die Lokalisation eines Objektes mitzuteilen das sich auf uns zubewegt (damit wir schnell flüchten bzw. abwehren können).

Wenn jemand einen Ball auf uns zuwirft ist es für unser Gehirn (und unsere Gesundheit/Sicherheit) erstmal völlig unwichtig welche Farbe dieses Objekt hat - nur die Richtung, die Geschwindigkeit und der Kurs sind entscheidend; dieser Teil der Informationsverarbeitung passiert in weniger als 100 Millisekunden. Haben wir uns dann in Sicherheit gebracht und haben mehr Zeit uns um das Objekt zu kümmern dann nehmen wir erst bewusst die Farbe und die genaue Form des Objektes war - das dauert über 250 Millisekunden.

Da diese beiden Pathways voneinander getrennt laufen, d.h. sie sind anatomisch eigenständig im Gehirn nachweisbar, kann man sie auch getrennt voneinander untersuchen.

Es gibt ein klinisches Phänomen namens "Blindsight" das dies sehr gut demonstriert: diese Patienten haben durch einen Mikro-Schlaganfall oder Tumor, etc. den "what" pathway verloren - er steht nicht mehr in Verbindung mit dem Bewusstsein, d.h. sie sind blind weil sie nicht mehr bewusst sehen können.

Trotzdem sind sie in der Lage die Position von Objekten im Raum zu bestimmen (zu erahnen). Die Trefferquote liegt dabei deutlich über dem was man erreicht wenn man nur raten würde.

Für normale Menschen hat diese Einteilung in 2 Pathways aber auch eine sehr wichtige Bedeutung: will man konzentriert an etwas arbeiten dann ist es wichtig dass im Sichtfeld und im peripheren Sichtfeld möglichst Ruhe herrscht - sonst werden wir über den automatischen Stellreflex ständig aus unserer Konzentration gerissen.

Der Stellreflex bewegt den Kopf nämlich automatisch in die Richtung in der eine Bewegung oder ein Geräusch auftaucht. Das war zu Zeiten von Säbelzahntigern und anderen Raubtieren in der Umgebung unserer Vorfahren ganz nützlich - und deswegen haben wir auch heute noch die gleichen Mechanismen in unserem Gehirn.

Auch "Visual Clutter", d.h. eine Umgebung mit jeder Menge kleiner Details lenkt unglaublich ab; deshalb sinkt die Produktivität enorm wenn der Schreibtisch an/auf dem man arbeitet mit Dingen übersäht ist.

In der (visuellen) Ruhe liegt die Kraft. ;-)

Diese Experimente zeigen sehr gut welche komplexen Bewegungen unser Gehirn/Körper ausführen kann ohne dass wir uns dessen bewusst sind.

Ein weiteres jedem bekanntes Beispiel sind z.b. die automatischen Reaktionen wenn man an Spinnen, Ratten, etc. denkt oder Bilder/Videos davon sieht.
Unserem Bewusstsein ist klar dass in dem Moment in dem man ein Bild einer Tarantel sieht keine echte vorhanden ist - unser autonomer Teil interessiert sich dafür aber nicht und löst trotzdem die "passenden" Reaktionen aus: Gänsehaut, Ekel, etc.

Der autonome Teil kennt in seinen Reaktionen nur das Motto "lieber zu früh als zu spät".
Diese automatischen Reaktionen ziehen teils starke Veränderungen in der Muskelansteuerung nach sich; werden sie oft hintereinander ausgelöst dann können sich Muskeln auch dauerhaft verspannen. Deswegen ist es wichtig seine Umgebung möglichst so zu gestalten dass sie nicht noch mehr zur dauernden Reflexauslösung beiträgt. Dazu zählt die Positionierung des Schreibtisches, des Monitors und (meiner Meinung nach) die Auswahl an Signaltönen die man am Telephon oder Computer einstellen kann.

Man darf diese Phänomene (und hunderte andere) nicht einfach als Spielerei oder Kuriositäten abhandeln; wenn man das Gehirn verstehen will, muss man sich mit diesen Sachen eingehend beschäftigen, denn nur darüber erkennt man wie unser Gehirn arbeitet.

Und nur wenn man den autonomen Teil direkt beeinflusst, kann man effektive Therapien entwickeln und anwenden.

Viva La Revolution! - Teil 3

2007-08-11T13:04:00.000-07:00

Das grösste Hindernis das es zu überwinden gibt wenn es um das Verständnis der Neuromatrix Theorie geht liegt leider in uns selbst.

Dan Dennett beschreibt es so: "Wenn man jemanden über Politik fragt hat er eine Meinung. Fragt man ihn über (sein) Bewusstsein ist jeder ein Experte - auch wenn das nicht der Fall ist".

In unserem Gehirn gibt es einen Bereich (den "Interpreter" nach Gazzaniga) dessen Aufgabe es ist unserem Bewusstsein Erklärungen zu liefern -auch wenn diese absolut absurd sind. Das ist nötig damit "wir" (unser Bewusstsein) zu jeder Zeit das Gefühl haben in Kontrolle zu sein und ein einheitliches und zusammenhängendes Körperbild erzeugt wird.

Am besten sieht man was passiert wenn dieses einheitliche Körperbild nicht mehr vorhanden ist: bei schizophrenen Patienten funktioniert das nicht mehr - deshalb hören sie manchmal Stimmen die eigentlich aber nur eigene Gedanken sind die ihr Gehirn nicht mehr als eigenerzeugt erkennt. Das gleiche passiert bei Menschen die z.b. ein "Alien Hand Syndrome" entwickeln - sie verlieren die Verbindung zu ihrer Hand die sich daraufhin wie von Geisterhand von selbst bewegt.

Das führt im Extremfall soweit dass sie versuchen sich selbst den Arm abzuschneiden (er ist ja kein Teil von ihnen) - oder der Körperteil amputiert wird.

Ein weniger extremes Beispiel das die meisten schon selbst erlebt haben ist z.b. das Gefühl eines eingeschlafenen Arms oder Fusses oder einer betäubten Wange nach einem Zahnarztbesuch - auch hier hat man oft den Eindruck das der betroffene Körperteil nicht mehr zu einem selbst gehört.

Ein kleines Experiment dazu ist die sogennante Kohnstamm-Illusion: dabei stellt man sich nah an eine Wand, die Arme hängen locker neben dem Körper. Dann drückt man so fest man kann mit dem Handrücken für ca. 1 Minute gegen die Wand. Danach macht man einen Schritt zur Seite und beobachtet was passiert - der Arm bewegt sich wie von alleine nach oben.

Hier wird das Körperbild für kurze Zeit verändert indem der "Richtwert" für den Grundtonus hochgesetzt wird - und selbst hier hat man schon das Gefühl dass einem der Arm nicht mehr gehorcht.

Wie man sehen kann ist es also absolut nötig eine einheitliche Illusion aufrechtzuerhalten weil wir sonst im Alltag nicht mehr funktionieren könnten.

Nur wenn man sich von dieser Vorstellung der eigenen Perfektion trennt kann man die Neuromatrix verstehen und damit arbeiten. Man muss nämlich diese Illusion sehen als was sie ist und ihre Schwächen ausnutzen - und davon gibt es jede Menge.

Am besten eignen sich dazu optische Illusionen - sie führen jedem vor wie ungenau unser wichtigster Sinn - das Sehen ist.

Diese "Schwäche" macht sich z.b. die Spiegeltherapie zunutze: unser Gehirn - also der autonome Teil den man beeinflussen will kann nämlich nicht unterscheiden ob er ein Spiegelbild sieht oder nicht und behandelt den visuellen Input als Realität.

Das Fernsehen benutzt eine der grössten Schwächen überhaupt: die Bilder die unseren Augen präsentiert werden sind ja alles Standbilder - es findet gar keine Bewegung statt. Da aber die Bildabfolge so dicht hintereinander erfolgt kann unser Gehirn die kurzen Pausen dazwischen nicht wahrnehmen und es ergibt sich das Gefühl von Bewegung.

Wir nehmen auch nicht wahr dass der Bildschirm aus vielen kleinen Punkten besteht die nur 3 Farben darstellen können - ab einer gewissen Distanz verschwimmen die Punkte zu einem einheitlichen Bild.

Viele andere Dinge im täglichen Leben machen sich somit unsere Fehler (?) zunutze - warum soll die Therapie dabei eine Ausnahme bilden?

Viva La Revolution! - Teil 2

2007-08-11T01:23:00.000-07:00

Basis der "Neuromatrix Theorie" ist es nicht mehr aus Sicht eines externen Beobachters zu denken, sondern sich in das Gehirn des Patienten zu versetzen - und zwar speziell den Teil der automatisch und unbemerkt seine Arbeit verrichtet.

Den Behandler interessiert nicht mehr das Körperbild das seine Augen haben - sondern das Körperbild das das Gehirn verwendet um Entscheidungen (z.b. über Bewegungen) zu treffen.

Beispiel: im "alten" Denkmodell war nach einer Amputation des Unterarms dieser nicht mehr vorhanden. Er war ja schliesslich nicht mehr zu sehen - weder für den Therapeuten noch für den Patienten. Deswegen konnte man sich auf Phantomschmerzen auch keinen Reim machen und keine effektive Therapie entwickeln. Die Therapien die es gab haben versucht periphere Auffälligkeiten zu verringern - Beseitigung von Vernarbungen, etc. - jedoch alle nur mit teilweisem Erfolg, d.h. nur ein kleiner Prozentsatz der Patienten hatte weniger Schmerzen und das auch nur für gewisse Zeit.

Im neuen Denkmodell (der "Neuromatrix") versetzt man sich in den autonomen Teil des Gehirns. Und dieser "sieht" sehr wohl noch einen Unterarm - weil die entsprechende Karte noch auf der Gehirnrinde vorhanden ist. Sie ist zwar verändert (siehe neurale Plastizität) - aber das stört wenig.

Da das neue Modell jetzt endlich die Ursache für diese Art von Schmerzen berücksichtigt ist es möglich geworden Therapien einzusetzen die über 90% Erfolgsquote aufweisen.

Die gute Nachricht dabei: alle Arten von chronischen Schmerzen teilen sich das gleiche Entstehungsprinzip - und sind daher mit ähnlichen Techniken behandelbar.

Die Suche nach eindeutigen Schäden war und ist ja auch im Bereich (chronischer) Rückenschmerzen katastrophal fehlgeschlagen. In den meisten Fällen - bei den sogenannten unspezifischen Schmerzen - lassen sich keine Auffälligkeiten finden die die Schmerzen und das Schmerzverhalten erklären können.

Nach dem neuen Modell geht man davon aus dass es weniger einer Reparatur bedarf ,sondern dass die Therapie auf ein "Tuning"/ein "neu kalibrieren" des Bewegungsapparates hinauslaufen muss. Gordon Waddell ist hier der bekannteste (und beste) Vorreiter dieses Denkens.

Die Forscher die die genauen Einzelheiten untersuchen setzen sich aus einer bunten Mischung zusammen: die meisten sind Psychologen (v.a. experimentelle Psychologen), andere sind Ärzte - und auch der ein oder andere Physiotherapeut ist dabei (Lorimer Moseley).

Und wie im ersten Teil schon beschrieben: wer ist für die Umsetzung dieser Therapien im Alltag zuständig?

Offiziell gibt es noch keinen Beruf der das macht - wieso greifen wir nicht einfach zu!?

Und noch viel wichtiger: ist es moralisch vertretbar dass chronisch Schmerzgeplagte effektive Therapien vorenthalten werden einfach weil manche nicht bereit sind das alte Denkmodell aufzugeben? Müssen wir uns wirklich noch die alten Phrasen wie "so hab ich das (vor 20 Jahren) gelernt?" anhören und warten bis diese Leute in Rente gehen um etwas verändern zu können?

Möchten wir selber wenn wir alt werden und Schmerzen haben eine Erleichterung/Heilung oder sind wir mit dem zufrieden was "man schon immer gemacht hat" (auch wenn es nachweislich nicht hilft)?

Ich sehe das nicht so.

Und genau hier gibt uns das Internet die Möglichkeit endlich eine Verbindung zwischen den Wissenschaftlern und den Patienten herzustellen - zu deren Wohl (und mit deren Geld) die Forschung ja schliesslich betrieben wird.

Wir sind so in der Lage die Verbreitung neuer Therapien und Denkansätze massgeblich zu beschleunigen damit mehr Menschen geholfen werden kann. Mein Blog soll dazu seinen Beitrag leisten.

Wenn man sich anfangs mit der Neuromatrix Theorie auseinandersetzt und über die Möglichkeiten nachdenkt die sich auch in anderen Bereichen des täglichen Lebens ergeben kann einem schon mal der Kopf rauchen; aber keine Angst: je mehr man diesen Denkansatz versteht umso leichter wird es.

Viva La Revolution! - Teil 1

2007-08-10T11:25:00.000-07:00

Wissenschaft ist eine wunderbare Sache - aller Wahrscheinlichkeit nach die wichtigste Erfindung die die Menschheit je zustande gebracht hat. Mit wissenschaftlichen Methoden lassen sich alle bekannten (und teils noch unbekannte) Phänomene untersuchen.

Ob es sich dabei um die Laufbahnen der Planeten, den Sonnenuntergang oder das Verhalten von Bakterien handelt ist dabei egal. Die Werkzeuge des Wissenschaftlers sind immer die gleichen: das Phänomen beobachten, beschreiben, definieren - und davon ausgehend Theorien aufstellen. Diese Theorien werden dann getestet und mit dem tatsächlichen Verhalten verglichen woraufhin der ganze Prozess wieder von vorne startet.

Photosynthese ist einer dieser enorm wichtigen Prozesse den ich hier bildlich dargestellt habe:

Im Laufe der Jahre entwickeln sich Theorien also - sie unterliegen einem evolutionären Prozess; diejenigen die nicht in der Lage sind sich experimentell zu behaupten sterben aus.

Um diesen Level an Genauigkeit zu erreichen war - und ist es nötig - jedes Phänomen in seine kleinsten Bausteine zu zerlegen - man nennt das auch "Reduktionismus". Um z.b. im Ernährungsbereich Aussagen treffen zu können werden Lebensmittel in Kategorien wie Kohlehydrate, Eiweis, Vitamine, etc. aufgeteilt und separat untersucht.

Das ist bis zu einem gewissen Level auch nötig und sinnvoll - um aber die gewonnenen Erkenntnisse sinnvoll im alltäglichen Leben anwenden zu können ist eine "Re-Synthese" nötig, d.h. man muss andere - oft weit entferne Forschungsbereiche mit einbeziehen.

Ein Beispiel: Essen hat eine sehr starke soziale Komponente - es dient der Gruppenbildung und ist eine Art von "social grooming" die wir als Herdentiere brauchen. Isst man alleine fehlt also diese starke soziale/psychische Komponente. Deshalb fühlen sich Singles trotz evtl. besserer Ernährung (rein wissenschaftlich reduziert gesehen) bei weitem nicht so "angenehm satt" wie wenn man in Gesellschaft isst.

Auch die Geschwindigkeit mit der man seine Mahlzeiten zu sich nimmt hat einen grossen Einfluss auf das allgemeine Wohlbefinden - auch wenn der Nährwert gleich ist.

Diese Reduzierung auf einzelne Komponenten ist auch im medizinischen Bereich üblich - das sieht man alleine schon an der Unterteilung in die ganzen unterschiedlichen Fachgebiete: Orthopädie, Pädiatrie, Innere Medizin, etc.

Was macht man aber nun mit einem Patienten der an Rückenschmerzen leidet die er nach einer verheilten Wirbelsäulenfraktur hat? Ist er noch ein orthopädischer Patient (seine Knochen sind ja eigentlich wieder in Ordnung)? - oder ist er "ein Fall für den Psychologen" (denn Schmerz ist ein psychologisches Phänomen)?

Es gibt nach wie vor keinen Beruf dem offiziell die Behandlung eines solchen Falles zuzuteilen ist - obwohl immer mehr Studien und Erfahrungsberichte zeigen dass längst Zeit dafür ist.

Die neuen Technologien die uns durch das Internet zur Verfügung stehen haben die Welt kleiner und "flacher" gemacht wie Thomas Friedman beschreibt. Die alteingesessenen Institutionen und Denkweisen können mit diesen Entwicklungen nicht mehr Schritt halten. Daher ist ein radikales Umdenken aller beteiligten dringend erforderlich - ein Prozess der nicht ohne Herausforderung ist.

In der Literatur spricht man immer von "interdisziplinären Teams" die diese Aufgabe erfüllen sollen - etwas das wir in unserem Rehazentrum auch mit einigem Erfolg täglich praktizieren.

Ich möchte behaupten dass gerade die Physiotherapie ideal am Schneidepunkt steht und diese Aufgabe (in Zusammenarbeit mit allen anderen) sehr gut übernehmen kann.

Uns steht ein grosses Repertoire an Techniken und Möglichkeiten zur Verfügung - von passiven zu aktiven Anwendungen. Ausserdem haben wir in der Regel mehr Zeit mit dem Patienten zur Verfügung so dass wir auch ein gewisses Vertrauensverhältnis aufbauen können. So erfahren wir oft mehr als der behandelnde Arzt dem leider oft nur wenig Zeit zur Verfügung steht.

Wir müssen über die Grenzen schauen und viele verschiedene Bereiche unter einen Hut bringen. Daraus entsteht dann im Laufe der Zeit eine neue Theorie die unser Verständnis des menschlichen Körpers und seiner Funktionsweise komplett auf den Kopf stellt - die aber den Vorteil hat dass wir darauf basierend neue und effektive Behandlungsmethoden entwickeln und anwenden können.

Die Vorarbeit wurde zum Glück schon geleistet - durch die Arbeit von Melzack und Wall die dem ganzen den Namen "Neuromatrix Theory" gegeben haben.

In den nächsten Postings werde ich versuchen die Grundlagen dieser Theorie zu erklären. Es wird nicht einfach sein dem Ganzen zu folgen weil das meiste davon gegen unsere Intuition geht - aber genau das ist der Schlüssel zum Erfolg. Nur wenn wir begreifen wie imperfekt wir sind können wir uns verbessern.

Rezeptive Felder

2007-07-25T09:34:00.000-07:00

Wie schon mehrfach erwähnt, ist die Karte unseres Körpers die auf der Oberfläche des Gehirns liegt, nicht statisch - sie verändert sich laufend.
Wir wissen auch dass eine auf Feedback basierende Therapie - sei es visuell über einen Spiegel oder Monitor, oder durch konzentriertes Training - "krankhafte" Veränderungen dieser Karte sehr schnell rückgängig machen kann.
Nimmt man nun noch dazu dass bei chronischen Rückenschmerzpatienten das Ausmass der Veränderung direkt mit der Zeit in der der Schmerz besteht zusammenhängt (und mit der Schmerzstärke) - entsteht für mich ein klares Bild wo die Ursache von chronischen Schmerzen zu finden ist und wie man diesem vorbeugend entgegenwirken kann.

Unsere Nervenzellen (Neurone) sind für einen einzigen Zweck gebaut: Input zu empfangen. Neurone sind sehr extrovertiert ;-) und wollen ständig mit ihrer Umwelt in Kontakt stehen. Isoliert man eine Nervenzelle aus dem Gehirn und legt sie in Nährflüssigkeit in eine Petri-Schale so verlängert sie sich bis zu einem Drittel ihrer eigenen Länge! Neurone sind so "süchtig" nach Input dass sie alles nehmen was sich ihnen anbietet. Deshalb kann man sie auch mit Silikonchips bzw. "Computerchips" verbinden über die sie Signale empfangen können.

So stelle ich mir bildlich diesen Prozess vor:

Hier meine Theorie: die Neurone die für die Lendenwirbelsäule zuständig sind empfangen zu wenig Input; die Ursache dafür ist der allgemeine "Bewegungsmangel" an dem reiche Industriestaaten leiden. Wir lassen bewegen statt es selber tun zu müssen. ;-) Das Gehirn versucht nun die Auflösung unserer Karte zu verbessern indem es mehr Neurone für die Karte der Lendenwirbelsäule bereitstellt. Mehr Fläche bedeutet mehr Feingefühl. Auf diese Art und Weise kann man "künstlich" die Menge an Input vergrössern. Im Prinzip kann man diesen Vorgang als fehlgeschlagenen Reparaturversuch ansehen. Denn selbst mit mehr Auflösung kommen nicht mehr Informationen im Gehirn an und der Bereich der Lendenwirbelsäule bleibt "stumm".

Warum Schmerz als Resultat?
Das hat Harris in seiner Hypothese sehr gut beschrieben: je mehr Fläche der Lendenwirbelsäule zur Verfügung steht umso grösser die Diskrepanz zwischen Bewegungsabsicht, Bewegungsempfinden und Feedback (v.a. visuell). Deshalb steigt mit der Zeit die Schmerzintensität, das Areal (ausstrahlende Schmerzen) und die Karte auf der Gehirnrinde wird grösser. Werden die 3 Faktoren wieder in Einklang gebracht dann verkleinert sich der schmerzhafte Bereich sehr schnell und die Karte schrumpft.

Wie kann man präventiv vorgehen?:
wie schön wäre es wenn man sich einfach nur mehr bewegen muss wie es die diversen Werbebotschaften versprechen.
Ganz so leicht ist es dann doch nicht: viele Patienten sind enttäuscht wenn sich an ihren Schmerzen auch nach längerem Training nichts verändert. Meist werden nämlich beim Training die Prinzipien die ich hier beschrieben habe nicht beachtet so dass dem Gehirn gar keine Möglichkeit gegeben wird sich anzupassen und eine neue Struktur anzunehmen.
Andererseits sollte auch eine kleine feine Umstellung im Lebenswandel erfolgen - denn Training alleine reicht oft nicht aus.

Am meisten können wir von den Schimpansen lernen: ihr "Grooming behavior" - also das gegenseitige Fellreinigen ist dafür das beste Beispiel. Hier bekommt der Rücken jede Menge kleine Impulse. Etwas ähnliches kann man im Haushalt mit so einfachen Sachen wie einem rauhen Handtuch erreichen - oder der Badebürste die ich jedem nur wärmstens empfehlen kann. Natürlich gibt es auch spezielle Rückenkratzer, etc. etc.

Alles was die Haut am Rücken in kleinen Dosen "reizt" ist gut. Und das täglich.
Wer des öfteren unter Nackenverspannungen leidet sollte mal versuchen mit einer rauhen Bürste den Bereich zwischen den Schulterblättern intensiv abzubürsten. Die Kopfbeweglichkeit z.b. beim drehen nach rechts und links ist danach oft deutlich höher.

Am interessantesten bei dieser Art der Therapie (und Prävention) finde ich dass man nur die Hautoberfläche (!) behandelt und alle anderen Wirkungen - Muskelentspannung, etc. automatisch erfolgen. Es zeigt auf sehr schöne Art und Weise wie wichtig und einflussreich Informationsfluss sein kann.

Neurale Plastizität - Teil II

2007-07-07T03:28:00.000-07:00

Es wäre schön wenn man zum Thema neurale Plastizität nicht mehr sagen müsste als das sie existiert - damit aber die darauf basierende Therapie effektiv ist muss man wissen wie man sie gezielt beeinflussen kann.

In einem früheren Posting habe ich ja schon die Existenz von Karten auf der Gehirnrinde erklärt. Das Bild zeigt dass die Karte keine 1:1 Darstellung unseres Körpers ist - sondern auf der "Empfindlichkeit" und den feinmotorischen Fähigkeiten beruht. So sind die Hände riesig und z.b. die Beine sehr klein - weil wir den ganzen Tag mit den Händen greifen, schreiben, ... - und nicht mit den Beinen.

Bei Musikern lassen sich diese Veränderungen sehr gut nachweisen - und das nicht nur in dem Bereich der für die Hände zuständig ist - sondern auch im auditiven Cortex - also dem Bereich des Gehirns der für das hören zuständig ist. Das ist eine gute Nachricht für alle Tinnitus-Geplagten - denn basierend auf diesen Erkenntnissen kann man endlich eine effektive Therapie entwickeln die die Ursache behandelt und nicht nur die Symptome.

Welche Prinzipien muss man bei der Therapie beachten?

1) Im Tierversuch hat sich gezeigt dass wirklich nur der Bereich sich verändert der auch stimuliert wird; d.h. wenn ich ein Problem mit den Fingern habe muss ich diese einzeln und gezielt stimulieren; es reicht nicht aus Bewegungen mit der ganzen Hand auszuführen.

Da bei Dystonien und CRPS die Karten von zwei oder mehr Fingern miteinander "fusionieren" muss ich - um wieder eine ordentliche Abgrenzung herzustellen - die Finger einzeln trainieren.

2) Visuelle Kontrolle: bei Tierversuchen hat man die schnellsten Veränderungen gesehen (hin zu chronischem Schmerz) wenn man den Tieren kein visuelles Feedback gegeben hat und die Bewegungen sehr viel Feinmotorik erfordern. In diesem Fall ist das propriozeptive Feedback sehr gering und das Gehirn hat keine Möglichkeit zu sehen ob die gesendeten Befehle auch wirklich richtig ausgeführt werden. Man vermutet dass das Gehirn versucht dieses Defizit durch "Wachstum" der Karten zu kompensieren (weil eine grössere Karte eine höhere "Auflösung" zulässt) - und dieser Kompensationsmechanismus dann zur Fusion der Karten und chronischem Schmerz als Resultat führt. Auch bei chronischen Rückenschmerzpatienten sind die Karten stark vergrössert. Da es schwierig ist hier visuelles Feedback zu geben muss man auf andere Techniken ausweichen. Prof. Flor und ihre Gruppe verwenden z.b. verschiedene Stromfrequenzen die der Patient unterscheiden muss. Als Therapeut in einer Praxis kann man taktiles und verbales Feedback geben, etc.

3) Konzentration: nur wenn die Aufmerksamkeit auf den stimulierten Körperteil gerichtet ist zeigen sich Veränderungen. Der Erklärungsmechanismus in diesem Fall steht leider noch aus - es scheint aber so zu sein dass wir unserem Gehirn "zeigen" können was wichtig ist indem wir uns auf eine Sache konzentrieren. Ich vermute dass hier ein Zusammenhang mit unserem doch sehr begrenzten Arbeitsspeicher besteht. Da wir auch nur für ca. 10 Minuten in der Lage sind uns zu konzentrieren sollten die Trainingseinheiten kurz aber öfter pro Tag stattfinden. 3-4 Einheiten pro Tag sind effektiver als 30 Minuten am Stück. "Meine" Rückenschmerzpatienten sind sehr oft erstaunt wie anstrengend 10 Minuten sein können - obwohl sie dabei liegen und sich nur auf die winzigen Bewegungen konzentrieren müssen die ich ihnen zeige.

4) "Memory Consolidation": das ist der treffende Begriff für "eine Nacht drüber schlafen". Abends zu trainieren ist sehr effektiv weil das Gehirn dann über Nacht Zeit hat die neu-erlernten Dinge eingehend zu verarbeiten. Will man eine neue Bewegung erlernen braucht unser Gehirn eine lange Störungsfreie Pause um nicht-erfolgreiche Versuche auszusortieren und die neuen Nervenbahnen permanent miteinander zu verschalten - und das kann es am besten im Schlaf (der dann auch qualitativ besser wird! - ein sehr schöner Nebeneffekt).

5) Nicht übertreiben: unser Arbeitsspeicher (Kurzzeitgedächtnis) hat eine begrenzte Aufnahmefähigkeit; dies gilt sowohl für die Menge die reinpasst als auch wie lange man sich etwas merken kann. Wenn ich versuche eine neue Bewegung zu lernen wird der Speicher gefüllt. Ist die Bewegung fehlerhaft muss ich dem Gehirn also Zeit geben den Speicher zu löschen bis ich die Bewegung erneut ausführe! Macht man das nicht wiederholt man die falsche Bewegung immer und immer wieder. Sehr schön zu beobachten sind hier (alle) Erwachsenen: lässt sich z.b. eine Schublade nicht auf den ersten Versuch öffnen wird mit immer mehr und mehr Kraft (Gewalt) dran gezogen bis der ganze Schrank wackelt. Danach setzt sehr schnell Frustration ein und der Konstrukteur wird verflucht. Die Schublade bleibt trotzdem zu. ;-)

Der umgekehrte Weg ist wesentlich effektiver: nach dem ersten Versuch sofort stoppen, das Problem analysieren (und somit andere Informationen in den Arbeitsspeicher laden) - dann neuer Versuch - mit weniger Kraft und langsamerer Ausführung - und voila - es funktioniert.

Ich nenne ungern Zahlen - aber eine vor kurzem veröffentlichte Studie hat die Pausenzeit mit ca. 4 Sekunden benannt. Erst dann ist der Speicher wieder frei für neue Bewegungsmuster.

Hat man diese Prinzipien verstanden kann man für jedes chronische Problem eine geeignete Therapie entwickeln die sich direkt an den Möglichkeiten und den Bedürfnissen des Patienten anpassen lässt. Auch sogenannte "Hausaufgaben" kann man daraus sehr gut herleiten. Ob es sich dabei um einen Musiker der seine Finger nicht mehr einzeln bewegen kann (focale Dystonie), einen Tinnitusgeplagten oder einen chronischen Rückenschmerzpatienten handelt ist dabei egal - denn die Ursache und Therapie ist vom Prinzip her die gleiche.

Ach ja - die Prinzipien sind natürlich für alles anwendbar das mit "lernen" zu tun hat. Also auch Fremdsprachen, jonglieren, etc.

So sieht es übrigens in unserem Gehirn aus wenn wir etwas neues lernen:

Neurale Plastizität - Teil I

2007-06-28T10:58:00.000-07:00

Im Zusammenhang mit chronischen Schmerzsyndromen taucht immer wieder der Begriff "neurale Plastizität" auf. Es handelt sich dabei um einen Prozess der erst in den letzten Jahren - dank neuer bildgebender Verfahren - entdeckt wurde. Mit diesen Technologien kann man "dem Gehirn beim arbeiten zuschauen" - und damit sehen welche Bereiche zu welcher Zeit aktiv sind.

Man hat auch die Möglichkeit Veränderungen im Gehirn des Patienten im Laufe der Zeit zu dokumentieren - und so zu sehen ob und wie die Therapie das Gehirn verändert.

Auf diese Art und Weise hat man bereits bei vielen bisher als (fast) unheilbaren geltenden Erkrankungen entdeckt dass die ersten Veränderungen im Gehirn des Patienten auftreten - und dann erst nach und nach auch Symptome im Körper bzw. an den Extremitäten entstehen.

CRPS - auch bekannt unter den Namen Morbus Sudeck, Sympathische Reflexdystrophie, etc. ist eine dieser Problematiken; es ist primär eine Erkrankung des Gehirns! - die ganzen sichtbaren Symptome (Schwellung, Bewegungseinschränkungen,...) entstehen erst später - als Folgeerscheinung.

Eine symptomatische Behandlung ist in diesem Fall wenig hilfreich solange die (versteckte) Ursache nicht behoben werden kann.

Eine ähnliche Problematik sind auch Symptome die unter dem Begriff RSD/RSI zusammengefasst werden (Repetitive Strain Disorder/Repetitive Strain Injury). Im Deutschen u.a. bekannt als Tennisellenbogen oder der neu-kreierte "Mausarm". Bei vielen dieser Symptome findet man an der schmerzhaften Stelle (trotz intensiver Suche) keinerlei pathologische Veränderungen - die Sehnenansätze sind normal, nicht entzündet. Trotzdem sind Bewegungen (extrem) schmerzhaft. Auch hier finden sich bei Untersuchungen des Gehirns starke Veränderungen in der dem Körperteil zugeordneten Karte auf der Gehirnrinde.

Neurale Plastizität beschreibt also einen Prozess im Gehirn bei dem sich die tatsächliche Struktur unseres Gehirns verändert. Kurzfristig geschieht das über eine andere "Verschaltung" der Nervenzellen - langfristig über Neubildung von Synapsen und Nervenzellen so dass die Veränderungen "stabil" bleiben und auch Jahre später noch abgerufen werden können.

Das ist der Grund warum man z.b. das Fahrradfahren nie verlernt - es ist für immer fest in der Struktur unseres Gehirns gespeichert.

Dieser Prozess, der für das lernen so wichtig ist, hat aber auch einen grossen Nachteil: wir lernen unter Umständen Dinge die hinderlich sind - z.b. chronische Schmerzen. Im Deutschen hat sich der Begriff "Schmerzgedächtnis" dafür eingebürgert.

Theorie des Spiegeltrainings - Teil II

2007-06-17T04:17:00.000-07:00

Im ersten Teil habe ich den Funktionsmechanismus zusammengefasst; in diesem Posting möchte ich den neurophysiologischen Hintergrund erläutern.

Ein grosser Teil der Oberfläche unseres Gehirns ist für eine Karte der Körperoberfläche reserviert, d.h. jeder Körperteil lässt sich auf dieser Karte auffinden. Wir verwenden das gleiche Prinzip mit Landkarten und Stadtplänen. Die Vorteile liegen klar auf der Hand: möchte ich z.b. Entfernungen messen dann brauche ich nur auf der Karte nachschauen und muss die Strecke nicht in Wirklichkeit nachfahren.

Diese Karten sind in unserem Gehirn genetisch festgelegt, d.h. jeder besitzt eine Karte auf der 2 Arme, 2 Beine, etc. vorhanden sind - auch wenn die betreffende Person z.b. ohne Arme geboren wird! Ja - richtig gelesen - auch Menschen denen durch einen (Gen)Defekt eine Extremität fehlt können Phantomschmerzen empfinden weil ja die Karte dafür vorhanden ist.

Die Karten sind aber natürlich nicht statisch sondern werden laufend angepasst; so findet man bei Musikern (Violinisten) eine vergrösserte Darstellung der Finger einer Hand. Wo also mehr Input erzeugt wird - durch häufigen konzentrierten Gebrauch - vergrössert sich das Areal auf der Gehirnrinde.

Umgekehrt bei Amputationen: dort wird vom abgetrennten Körperteil kein Signal mehr empfangen und der entsprechende Teil auf der Gehirnrinde schrumpft; schlimmer noch: die benachbarten/angrenzenden Teile wandern in das Gebiet ein; daher ist es völlig normal dass Patienten die einen Arm verloren haben an der Wange empfindlicher werden - denn diese Bereiche liegen auf der Karte nebeneinander. Das was früher als vom Arm kommend empfunden wurde wird jetzt auf die Wange und den Arm umgeleitet.

Diese Änderungen in der Hardware des Gehirns bezeichnet man als "Neurale Plastizität"; sie finden auch statt wenn man neue Bewegungen erlernt. Manche dieser Veränderungen sind erwünscht (eben wie beim lernen) - bei chronischen Schmerzsyndromen sind sie aber eher nachteilig weil das Endergebnis chronischer zentral erzeugter Schmerz ist.

Durch das Spiegeltraining (und auch andere Therapieformen, die normales Feedback wiederherstellen) kann man diese Prozesse rückgängig machen und dauerhafte Erfolge erzielen.

Theorie des Spiegeltrainings - Teil I

2007-06-07T00:57:00.000-07:00

Spiegeltraining (besser: Training mit visuellem Feedback) funktioniert - basta.

Man hat es inzwischen mit fast allen chronischen Schmerzsyndromen versucht (Phantomschmerz, CRPS, Querschnittlähmungen, Schlaganfall, ...) und die Ergebnisse sind immer die gleichen: kurze Trainingsdauer führt zu schnellen und v.a. langanhaltenden Erfolgen.

Was ist das besondere an dieser Art der Therapie das den Erfolg ausmacht?

Wen man nicht viel Zeit hat und nur eine einzige Studie lesen möchte kommt man um die hier nicht rum:

A.J. Harris "Cortical Origin of Pathological Pain", THE LANCET • Vol 354 • October 23, 1999

Es ist genaugenommen keine Studie, sondern "nur" eine Hypothese - aber da sie noch aus dem letzten Jahrtausend stammt ;-) und man inzwischen fleissig weitergeforscht hat wurde inzwischen alles bestätigt was Harris noch als Spekulation bezeichnete.

Meine Zusammenfassung:

Jeder kennt das Gefühl das man empfindet wenn die Information die uns unser Gleichgewichtsorgan liefert nicht mit der Info übereinstimmt die unsere Augen liefern.

Bezeichnungen dafür sind z.b. Seekrankheit, Reisekrankheit, etc.

Dabei ist es völlig egal ob sich der Körper bewegt und die Augen keine Bewegung wahrnehmen oder umgekehrt.

Wer noch nie einen First-Person-Shooter erlebt hat dem wird normal nach kürzester Zeit übel (das zuschauen reicht dabei schon aus). Richtschützen in modernen Kampfpanzern erleben das umgekehrte Gefühl bei der Fahrt durchs Gelände - denn ihre Optiken sind stabilisiert, d.h. sie sehen keine Bewegung obwohl ihr Körper sich heftig bewegt.

Das Besondere an dieser Empfindung: das Endresultat ist nicht Schmerz, sondern Übelkeit. Vermutlich deshalb weil unser Gehirn Schwindel als von einer Vergiftung ausgehend interpretiert und Übelkeit erzeugt um den Magen leerzupumpen.

Harris spekuliert dass chronischer Schmerz nach dem gleichen Muster funktionieren könnte - basierend auf einer Inkongruenz zwischen Bewegungsabsicht, Bewegungsempfinden und visuellem Feedback. Es wurde nämlich eine Region im Gehirn entdeckt die dann aktiv wird wenn sich zwischen diesen 3 Faktoren Unstimmigkeiten ergeben.

Da - besonders bei Phantomschmerz - kein visuelles Feedback mehr existieren kann, weil der betroffene Körperteil nicht mehr vorhanden ist, ist auch klar. Und genau dieses Problem kann man eben mit dem Spiegel sehr elegant lösen: das Spiegelbild der noch vorhandenen Extremität sieht aus wie der fehlende Teil. Und da unser Gehirn nicht zwischen Realität und optischen Täuschungen unterscheiden kann (siehe die Postings zum Thema fehlerhafte Wahrnehmung) sieht es das Spiegelbild als echt an und der Schmerz verschwindet.

Schmerz entsteht erst wenn alle automatischen Mechanismen die unserem Gehirn zur Verfügung stehen ausgeschöpft sind (Schonhaltungen, etc.); erst dann empfinden wir Schmerz der uns durch die starke emotionale Komponente dazu bringen soll "etwas (dagegen) zu unternehmen". In diesem Fall sehe ich Schmerz nicht als Warnsignal, sondern eher als ein Zeichen dass unser Gehirn nicht in der Lage ist aus einer Situation Sinn zu machen und deshalb "uns" einschaltet damit wir uns darum kümmern.

Ob Frösche auch Phantomschmerz empfinden kann ich leider nicht sagen ;-):

Phantomschmerz

2007-06-02T12:05:00.000-07:00

Die vorausgegangenen Postings haben gezeigt wie ungenau unsere Wahrnehmung in Wirklichkeit ist. Wir empfinden es anders - aber dieses Gefühl ist auch nur eine "Fassade" die uns von unserem eigenen Gehirn vorgetäuscht wird.
Ist vermutlich auch besser so - denn ohne das Gefühl Kontrolle zu haben würden wir nicht lange überleben; diesen Effekt sieht man sehr schön in Experimenten in denen man jemandem experimentell Schmerzen zufügt:
Personen denen man sagt dass sie das Experiment jederzeit abbrechen können empfinden den gleichen Reiz (Hitze, Strom, ...) als weit weniger schmerzhaft als Probanden die nichts machen können.

Im Tierversuch zeigt sich ausserdem dass Stresssituationen die nicht kontrolliert werden können zu all den typischen Problemen führen wie Bluthochdruck, Magengeschwüren, etc. - während das Gefühl Kontrolle über die Situation zu haben das verhindert.

Zurück aber zu unserer Wahrnehmung: die "Fehler" die unser Gehirn macht wenn es um das Sammeln von Informationen geht kann man auch nutzen um z.b. chronische Schmerzen zu behandeln.

Eine der schwierigsten Situationen im Bereich chronischer Schmerz ist Phantomschmerz. Die bisherigen Erklärungsmodelle sind alle gescheitert weil sie leider das Gehirn des Patienten völlig ausser acht gelassen haben. Man hat versucht alles mit einer rein peripher anatomischen Veränderung zu erklären, d.h. abgetrennte Nerven, etc.
Niemand ist auf die Idee gekommen eine Therapie zu entwickeln die die Sichtweise des Gehirns des Patienten mit einbezieht. Bis V.S. Ramachandran die "Mirror-Box" Therapie entwickelt hat.

Dabei wird dem Gehirn vorgetäuscht dass der amputierte Körperteil noch vorhanden ist und ganz normal bewegt werden kann; da das Gehirn dann keinen Konflikt mehr zwischen Bewegungs- und visueller Information erkennen kann hört der Schmerz nach wenigen Minuten auf:

Die ganze Therapie umfasst natürlich einen etwas längeren Zeitraum - also mehrere Trainingseinheiten pro Tag über mehrere Wochen - aber die Resultate sind so vielversprechend - und v.a. sofort zu spüren - dass es sich wirklich lohnt es zu probieren.

Die gleiche Technik kann man auch für andere schwerwiegende chronische Schmerzprobleme verwenden - allen voran CRPS - hier in Deutschland leider noch unter den Bezeichnungen Morbus Sudeck und Sympathischer Reflexdystrophie bekannt. Allerdings ist es dabei oft nötig die Therapie dabei zunächst auf einem niedrigeren Level zu starten da die Empfindlichkeit teils so hoch ist dass die Spiegeltherapie nicht gleich am Anfang verwendet werden kann.

Ach ja - da Phantomschmerz hier in Deutschland sehr gut erforscht wurde kann man alle Prinzipien die in der "Mirror-Box" Anwendung finden auch auf chronische Rückenschmerzen übertragen denen man dann ein für allemal Ade sagen kann - genau das also was ich in der täglichen Praxis mache.

Künstliche Intelligenz

2007-05-30T12:36:00.000-07:00

Ich muss gestehen dass ich das Thema künstliche Intelligenz (KI) nicht sehr genau verfolge. Was ich aber selber miterleben durfte war die Euphorie Ende der 80er Jahre in denen manche glaubten dass Problem wäre bald zu lösen - man braucht einfach nur mehr Rechenleistung.
Seitdem hat man nicht mehr viel von diesen Vorhersagen gehört und die meisten Ansätze sind im Sand verlaufen.

Ich frage mich auch immer wie wir eigentlich künstliche Intelligenz erzeugen wollen wenn wir noch nicht einmal wissen wie "echte" Intelligenz aussieht?
Der vielversprechnedste Ansatz meiner Meinung nach ist der von Jeff Hawkins.

Dieser Clip zeigt - auf humorvolle Weise - einige der Probleme die mit potentieller KI auftreten könnten:

Der Toaster lässt sich von seinem einprogrammierten Weg nicht abbringen und findet das eine Produkt welches seinen Spezifikationen entspricht ("So you're a waffle man"). Er ist nicht in der Lage zu abstrahieren sondern nimmt die Beschreibung wörtlich - etwas das wir Menschen genau umgekehrt perfektioniert haben - siehe dazu auch mein Posting zum Thema Kategorien.

Farben können lügen

2007-05-23T13:04:00.000-07:00

Farben sind ein sehr wichtiger Bestandteil unseres täglichen Lebens.
Und wie bei allen Dingen mit denen wir täglich zu tun haben, stellt man fest, dass bestimmte Erwartungen/Vorhersagen von unserem Gehirn getroffen werden.
Diesen Effekt kann man ausnutzen um z.b. die Illusion von Tiefe in ein zweidimensionales Bild zu bringen.
Penn & Teller zeigen diesen Effekt sehr schön in diesem Videoclip:

In der Photographie macht man sich diesen Effekt auch zunutze - der graduierte Hintergrund lässt das Bild "tiefer" erscheinen als es in Wirklichkeit ist:

Optische Illusionen sind deshalb ein so wichtiges Werkzeug im Bereich der Neurowissenschaften weil sie auf relativ einfache Art und Weise zeigen auf welchen (simplen) Regeln unser Denken und unsere Wahrnehmung beruht.
Die gleichen Prinzipien sind ausserdem auf alle anderen Arten der Wahrnehmung übertragbar; so gibt es z.b. genauso auditive Illusionen (wir hören Instrumente die gar nicht gespielt werden) - und v.a. sensorische Illusionen.

Optische Illusionen sind weithin bekannt und werden leider mehr als Vergnügen und kurzweiligen Zeitvertreib angesehen. Beschäftigt man sich aber intensiver mit ihnen und entdeckt die Querverbindungen u.a. zum Thema Schmerz kann man sie als wertvolle und extrem leistungsfähige Werkzeuge ansehen. Dazu aber in anderen Postings mehr.

Ein Tip noch zum Schluss - auf dieser Website findet man jede Menge verschiedener optischer Illusionen die auch immer wieder durch Neuzugänge erweitert wird.
Ich möchte jedem besonders diese Art von Illusion ans Herz legen.
Einfach für 20-30 Sekunden in die Mitte des Bildes schauen und danach am besten auf den eigenen Handrücken.
Selbst wenn man weiss dass sich da nicht wirklich etwas bewegen kann ist es unmöglich diesen Effekt zu unterdrücken. Das sollte einem einen Hinweis darauf geben welche "Macht" unser visuelles System ausüben kann.

Wahrnehmung und Erwartungshaltung

2007-05-17T03:18:00.000-07:00

In den vorausgegangenen Einträgen habe ich versucht zu zeigen dass unsere Wahrnehmung nicht so perfekt ist wie wir glauben. Wenn wir abgelenkt sind ist es möglich vor unseren Augen gravierende Veränderungen an einer Szene vorzunehmen ohne dass sie uns auffallen bzw. bewusst werden.

Ein mögliches Gegenargument ist dass die Beispiele die ich dafür gepostet habe alle mit Bewegung zu tun hatten und dass man bei einer statischen Szene kein Problem hätte bestimmte Details zu erkennen.

Zum Glück habe ich dafür vor einiger Zeit ein entsprechendes Photo gemacht:

Die Aufgabe: dieses Bild intensiv für ca. 1 Minute studieren und dann alle Auffälligkeiten beschreiben - die "Auflösung" erfolgt weiter unten.

Der deutsche Titel des Bildes ist "Blutbad" - ein Begriff der mindestens zwei verschiedene Bedeutungen haben kann: in der Regel stellen wir uns darunter ein Massaker vor. Die nicht-Erfüllung dieser Erwartung kann man in der Photographie (und auch anderen Bereichen) bewusst ausnutzen um einen "Aha" Effekt zu erzeugen.
Dadurch wird der Betrachter vom passiven zum aktiven Teilnehmer. Erst so wird aus einem Handwerk "Kunst" - und damit zu einem befriedigenden Erlebnis. Der Effekt eines Kunstwerks besteht in der Interaktion zwischen Zuschauer (dem Gehirn der Person) und dem betrachteten Objekt (Bild, Photo, Statue, Film, etc.).
Kunst basiert auf "simplen" Regeln die V.S. Ramachandran hier vorstellt.
Ich kann die ganze Serie seiner Reith Lectures nur wärmstens empfehlen.

Zurück zum Bild:
ich bin noch weit davon entfernt auch nur eines meiner Bilder als "Kunst" zu bezeichnen. Ich befinde mich noch viel zu sehr in der "handwerklich geschickten" Phase was das photographieren angeht. Aber ich finde immer und immer wieder dass meine beiden Hauptinteressen - Neurowissenschaften und Photographie - eine automatische Verbindung in meinen Bildern finden. So wie auch in diesem kleinen "Werk".

Und jetzt zur "Lösung":
wie schaut man sich so ein Bild an?
Wenn man das Photo zum ersten Mal sieht fängt unser Gehirn sofort an das Ganze in Einzelteile zu zerlegen und bestimmten Kategorien zuzuordnen; diese sind u.a. Bad, Spielzeug, Playmobil, Möbel, Photo, etc.
Danach wird weiter in Unterkategorien aufgeteilt: Badewanne, WC, Brause, ....

Und genau hier liegt das Problem:
Da unser Gehirn auf maximale Reaktionsgeschwindigkeit eingestellt ist (was ganz nützlich ist wenn man in der Wildnis überleben will) übernimmt es die Information über dieses Bild aus der entsprechenden Kategorie!, d.h. es verwendet nicht die tatsächliche visuelle Information sondern die Information die vor 20 Jahren oder mehr über das Konzept "Bad" abgespeichert wurde!
Unser Gehirn "erwartet" etwas (über das Konzept Bad) was gar nicht vorhanden ist bzw. bemerkt etwas nicht was tatsächlich vorhanden ist. Dadurch übersehen wir Details.

Wieso ist es denn so schwer in einem Text Schreibfehler zu finden den wir selbst geschrieben haben? Weil wir den Text nicht wirklich lesen wenn wir ihn versuchen zu korrigieren.
Der Text liegt in unserem Gedächtnis natürlich fehlerfrei vor; wenn wir ihn vom Papier oder Bildschirm lesen rufen wir die Information nicht visuell ab (dauert zu lange) - sondern unser Gehirn sendet die abgespeicherte Version. Deshalb übersehen wir selbst gravierende Fehler.
Um das Gehirn zu überlisten kann man Texte z.b. rückwärts lesen (also am Ende anfangen) weil dann unser Gedächtnis nicht eingreifen kann.

Warum ist unserem Gehirn Geschwindigkeit so wichtig und wieso probiert es immer (über Erwartungshaltungen) alles vorauszusehen?
Dank unserer Evolution wurden die "Träumer" aussortiert. ;-)
Derjenige der bei der geringsten Gefahr reagieren konnte hat überlebt. Wenn ein Raubtier plötzlich hinter einem Baum vorspringt ist es wichtig mich schnell in Deckung zu bringen - das kann ich machen wenn ich das Tier auf den ersten Blick in die Kategorie "Gefahr" unterbringen kann.
Deshalb erschrecken wir auch heute noch vor harmlosen Dingen die plötzlich auftauchen. Würde man sich Zeit für die Unterkategorisierung nehmen wäre man sehr schnell sehr tot.
Unsere Reaktion wird also durch die Kategorie bestimmt die unser Gehirn verwendet - nicht durch das was tatsächlich vorliegt.

Zum Bild: keine der Kategorien die wir verwenden enthält die Information dass Playmobilfiguren Mundwinkel haben die nach unten zeigen. Und noch viel weniger dass Augen und Mund schwarz sind. Playmobils haben immer braune Augen und grinsen die ganze Zeit. Und da unser Gehirn in Kategorien denkt fällt niemandem auf dass diese Figur anders ist. Wer es trotzdem bewusst wahrgenommen hat erhält 100 Punkte.

Die Verbindung zum Thema Schmerz ist ebenfalls sehr einfach (und unglaublich wichtig in der Therapie):
bei chronischen Patienten werden teilweise Bewegungen (bücken, heben, ...) in Kategorien eingeordnet bzw. Kategorien aktiviert die nichts mit dem tatsächlichen Geschehen zu tun haben! In diesen Fällen reicht es aus nur an eine Bewegung zu denken um eine Schmerzattacke zu provozieren. Das Gehirn erwartet Schmerz und löst ihn vorsichtshalber schon im voraus aus (Erwartungshaltung).
In diesem Fall muss die Software "umprogrammiert" und die fehlerhafte Einteilung gelöscht werden.
Wer hätte gedacht dass man durch ein einfaches (und lustiges) Photo einen der wichtigsten Grundsätze der Schmerzforschung erklären kann?!

Die meiste Zeit sind wir alle blind

2007-05-13T12:47:00.000-07:00

Psychologen und Neurowissenschaftler aller Richtungen haben in den letzten 50 Jahren sehr viel über uns Menschen herausgefunden. Das meiste was sie dabei entdecken ist erschreckend: wir haben kein gutes Gedächtnis sondern merken uns nur das Ergebnis einer Situation und erfinden die Details erst dann wenn wir versuchen die Erinnerung wieder abzurufen, unser momentaner "Gemütszustand" beeinflusst wie wir uns erinnern - d.h. ob die abgerufene Episode positiv oder negativ war, etc.
Auch was den Umgang mit unseren Mitmenschen angeht hat man vieles entdeckt - dazu einige Beispielvideos. Ich empfehle den dritten Video von oben.

Mit diesem Video kann man sich selbst testen (ist 6MB gross): die Aufgabe ist es nur! die Ballwechsel zwischen den Spielern mit den weissen T-Shirts zu zählen! Bitte nur die weissen Shirts!
Nachdem der Video vorbei ist sollte man sich das Ganze nochmal in Ruhe anschauen.

Und hier noch ein Video das zeigt warum Querdenken so viel Spass macht: das gleiche Prinzip (Ablenkung) kommt auch bei Penn&Teller (und anderen Magiern) zum Einsatz:

Fazit: ein Prinzip (unsere Konzentration kann nur an einem Ort zu einer Zeit sein) - und verschiedene Art und Weisen wie sich das im Alltag äussert und wie man es - z.b. für die Therapie nutzen kann.

Aufmerksamkeit, Konzentration und Multitasking

2007-05-13T07:21:00.000-07:00

Aufmerksamkeit bzw. Konzentration ist im Bereich Schmerz ein sehr wichtiger Faktor; wird einem Schmerz, der eigentlich "harmlos" ist, zu viel Bedeutung zugemessen, so wird er stärker empfunden. Dieser Effekt betrifft den psychologischen Anteil der in einem Schmerzerlebnis mitspielt.

In der Schmerzbewältigung macht man sich diesen Effekt zunutze und versucht dem (chronisch) geplagten Patienten Ablenkungsstrategien beizubringen, die er selber nutzen kann wenn er merkt, dass seine Aufmerksamkeit anfängt sich auf den Schmerz zu konzentrieren.

Auch im akuten Bereich kommen diese Techniken zum Einsatz: unser Betriebsarzt fordert den Patienten auf zu husten wenn er ihm eine Spritze gibt und sticht dann im richtigen Moment zu.
Bei schweren Verbrennungen hat man die Möglichkeit den Patienten über eine Brille in eine virtuelle Umgebung zu versetzen in der er ein Spiel spielt, etc. um so die Stärke des Schmerzes - medikamentenfrei! - um über die Hälfte zu reduzieren.

Wie funktioniert das Ganze?
Die kurze Antwort: wir sind nicht multitaskingfähig. Zumindest nicht so wie wir uns das vorstellen; ja - wir können mehrere Sachen gleichzeitig machen - aber wir verlieren viel Konzentration und Effektivität dabei, weil unser Gehirn beim Wechsel von einer Aufgabe auf die andere viel Zeit verliert.
Konzentriert man sich also auf eine einzelne Sache dann "vergisst" man für diesen Zeitraum alles andere; daher fragt man sich auch oft wo die Zeit geblieben ist wenn man konzentriert an einem Projekt arbeitet.
Es gibt sehr nette Videos wie dieses hier die den Effekt sehr eindrucksvoll darstellen: